A farewell to Lefty, politics, & acupuncture

Thanks again for all your well-wishes. I just got the call from Dr. Y, and he told me that Lefty stopped growing. 😦 In the words of IVFfervescent gal, I hope he enjoyed his few days on earth.

We have our WTF appointment scheduled for Friday at 9am.

*****

The news of the end of Lefty’s fight was somewhat softened by this morning’s Supreme Court rulings. I don’t mean to get political on y’all, but as an infertile heterosexual Californian, I’m grateful that SCOTUS rejected the argument that the ability to procreate was a prerequisite to a valid marriage… (No really, that was “the essential thrust of” the defendants’ position!) 

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In other news, I did something very unscientific yesterday. I went to see an acupuncturist who specializes in infertility, let’s call her J. I learned about her on the forum of my local Resolve support group, where she has rave reviews. She is also conveniently located 7 minutes from my house, and had an evening appointment available for the next day.

C and I arrived at J’s office at 5:30 and went in. She read over my forms (9 pages of them!) and asked some questions about me and my future treatment plans. The stuff she said sounded reasonable. She didn’t promise to cure my diminished ovarian reserve or improve egg quality. She said that our goal would be to increase blood flow to my lady organs, and hopefully achieve subtle improvement in my antral follicle count. She expressed interest in hearing what Dr. Y says to us at our upcoming appointment so she can adjust our treatment plan accordingly. We also discussed coffee and alcohol and supplements (more on those in a future post). C asked her whether she could do anything for his rib and back pain from the accident. She said she would be glad to once she got me set up.

The mood of the office was very spa-like: dim lighting, relaxing New Age music, faint smell of incense and massage oil. J had me strip except for bra & underwear and lay on my back on the table (which resembled a massage table), covered by towels. She directed a heat lamp at my feet; put needles in my tummy, arms, hands and feet; and covered my eyes with an eye pillow. I didn’t feel much as the needles went in. Then she did moxibustion (burning a cigar-like stick of mugwort to warm the regions where the acupuncture needles were). Lastly, J started a CD of ‘Meditations for the Fertile Soul’ by Randine Lewis and placed a bell in my hand, in case I needed anything. Then she left and took C to another room.

I’m not a very good meditator. I tried, but my mind would wander after a few minutes each time. But I was pretty relaxed, and the heat lamp felt good.

J came back (30 minutes later? 45 minutes?), removed the needles, put a heat pad on my belly, and massaged my back, shoulders, and feet with a peppermint-scented massage oil. And that was it!

With the support group discount ($10 off), she charged me $115 for this visit, with future visits costing $75. She didn’t charge at all for C’s treatment, which included acupuncture and cupping therapy. (C is Vietnamese, and despite usually being pretty skeptical, he seems to have inherited a belief in the efficacy of Eastern medicine from his parents.)

Overall, we were both pleased and plan to go back once a week for the time being.

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So, why do I say acupuncture is unscientific?

Here’s what I learned about acupuncture from a few hours of PubMed searching and reading abstracts. (As I mentioned before, I am not an expert. Specifically, I have no idea whether certain journals or researchers are more or less credible, though I speculate below about their possible biases…)

First, I looked for PubMed articles about acupuncture and diminished ovarian reserve:

Well…There aren’t many. A PubMed search of “acupuncture diminished ovarian reserve” turned up no hits; modifying the search to “acupuncture ovarian reserve” returned a whopping three hits. “Acupuncture AMH” returns a single article about treating PCOS. “Acupuncture FSH” turned up more, but most were about PCOS or treating menopausal symptoms…

In conclusion, I don’t think a lot of people have studied the effect of acupuncture on egg quality or quantity, but here are promising quotes from the abstracts of a few of the articles I found:

  • “Electroacupuncture therapy has a good clinical effect for IVF patients with poor ovarian reserve, and can improve oocyte quality and pregnancy outcome.”
  • There was “no statistical difference in the number of retrieved oocytes and the fertilization rate…Acupuncture combined CM-MTSSG [Chinese materia medica for tonifying shen and soothing gan] could obviously alleviate unfavorable emotions as anxiety and depression in patients with IVF-ET, effectively improve the treatment outcomes. Its effects might be correlated with lowering the excitability of the sympathetic nervous system, elevating the quality of oocytes, and improving the endometrial receptivity.” [my emphasis]
  • “The results suggest that electroacupuncture could decrease serum FSH and LH levels and increase serum E2 level in women with primary ovarian insufficiency with little or no side effects; however, further randomized control trials are needed.”

Next, I tried to find PubMed articles about acupuncture and IVF:

A PubMed search of “acupuncture IVF” returned 63 hits. Most of these were about the effect of acupuncture on embryo transfer, some were about acupuncture analgesia during egg-retrieval, and others were about acupuncture and male factor infertility.

The articles fell into four major categories:

  1. Articles that said acupuncture is effective
  2. Articles that said acupuncture is ineffective
  3. Articles that said acupuncture is effective, but that its effectiveness can be attributed to the placebo effect
  4. Articles that said there is not enough evidence to say

The majority of articles in Category 1 appear in journals with titles like Acupuncture in Medicine, Journal of Alternative and Complementary Medicine, Complementary Therapies in Clinical Practice, Zhonguo Zhen Jiu [translation: Chinese Acupuncture & Moxibustion], Zhongguo Zhong Xi Yi Jie He Za Zhi [translation: Chinese Journal of Integrated Traditional and Western Medicine], Evidence-Based Complementary and Alternative Medicine, and Clinical Journal of Integrated Medicine.

Now, I don’t want to say that these journals are suspect, but I think it’s fair to say that their titles at least suggest a belief in the efficacy of acupuncture…

Some quotes from abstracts that supported acupuncture:

  •  “The results mainly indicate that acupuncture, especially around the time of the controlled ovarian hyperstimulation, improves pregnancy outcomes in women undergoing IVF.”
  • “Transcutaneous electrical acupoint stimulation, especially double transcutaneous electrical acupoint stimulation, significantly improved the clinical outcome of embryo transfer.” (I think it’s worth noting that this was an article in Fertility and Sterility.)
  • “acupuncture can improve the outcome of IVF-ET, and the mechanisms may be related to the increased uterine blood flow, inhibited uterine motility, and the anesis of depression, anxiety and stress. Its effect on modulating immune function also suggests helpfulness in improving the outcome of IVF-ET. Even though a positive effect of acupuncture in infertility has been found, well-designed multi-center, prospective randomized controlled studies are still needed to provide more reliable and valid scientific evidence.”
  • “In this study, there appears to be a beneficial regulation of cortisol and prolactin in the acupuncture group during the medication phase of the IVF treatment with a trend toward more normal fertile cycle dynamics.” (Another article in Fertility and Sterility.)
  • “Limited but supportive evidence from clinical trials and case series suggests that acupuncture may improve the success rate of IVF and the quality of life of patients undergoing IVF and that it is a safe adjunct therapy. However, this conclusion should be interpreted with caution because most studies reviewed had design limitations, and the acupuncture interventions employed often were not consistent with traditional Chinese medical principles. The reviewed literature suggests 4 possible mechanisms by which acupuncture could improve the outcome of IVF: modulating neuroendocrinological factors; increasing blood flow to the uterus and ovaries; modulating cytokines; and reducing stress, anxiety, and depression.”
  • “Luteal-phase acupuncture has a positive effect on the outcome of IVF/ICSI.”

The majority of articles in Categories 2-4 appear in journals with names like Fertility and Sterility, Human Reproduction, BJOG – An International Journal of Obstetrics and Gynaecology, and Clinical and Experimental Obstetrics & Gynecology.

One might argue that these journals – which focus on Western medical interventions – might be biased against acupuncture and other alternative therapies.

Some quotes from abstracts that did not support acupuncture:

  • “When studies with and without placebo controls were analyzed separately, a placebo effect was suggested.”
  • “No significant benefits of acupuncture are found to improve the outcomes of IVF or ICSI.” (Perhaps also worth noting that this was an article in the Journal of Alternative and Complementary Medicine.)
  • “New emerging evidence from clinical trials demonstrates that acupuncture performed at the time of embryo transfer does not improve the pregnancy or live birth outcome after treatment.”
  • “There was no statistically significant difference in the clinical or chemical pregnancy rates between both groups [true acupuncture vs. sham acupuncture]… There were no significant adverse effects observed during the study, suggesting that acupuncture is safe for women undergoing ET.”
  • “Currently available literature does not provide sufficient evidence that adjuvant acupuncture improves IVF clinical pregnancy rate.”
  • “The use of acupuncture in patients undergoing IVF was not associated with an increase in pregnancy rates but they were more relaxed and more optimistic.”
  • “Acupuncture performed twice weekly during the follicular and luteal phase does not seem to improve pregnancy rates following IVF-ET.”

Particularly interesting were the articles that explored the possible placebo effect of acupuncture. Many of these studies used “sham” acupuncture needles that don’t actually penetrate the skin (in one case referred to as the Streitberger control). What they generally found is that patients who did sham acupuncture got the same benefit as (or in one case greater than) those receiving real acupuncture. Here are some quotes from abstracts that addressed the placebo effect of acupuncture:

  • “Placebo acupuncture was associated with a significantly higher overall pregnancy rate when compared with real acupuncture. Placebo acupuncture may not be inert.”
  •  “Acupuncture improves clinical pregnancy rate and live birth rate among women undergoing IVF based on the results of studies that do not include the Streitberger control. The Streitberger control may not be an inactive control.” (In Fertility and Sterility.)
  • “Even if adjuvant acupuncture were to increase IVF success rates only through a psychosomatic effect mechanism, such as by reducing stress, this stress-reduction effect would be integral to the working mechanism by which adjuvant acupuncture increases IVF pregnancy rates; therefore, it seems inappropriate to control for and separate out any such stress-reduction effect by using a sham control.” (In Reproductive Medicine Online.)

So why am I doing acupuncture?

Not one of the studies I saw in my search showed a negative impact of acupuncture on pregnancy rates. And very few said there was no improvement relative to no acupuncture. Rather, they said that there was no improvement relative to sham acupuncture. They also seemed to agree that patients enjoyed acupuncture, and that there was likely a psychological benefit. The fact also remains that the Chinese have been performing acupuncture for thousands of years, which in my mind affords it a level of credibility beyond that of other ‘unproven’ treatments.

So, I think that acupuncture might help – either by “correcting my flow of qi” and thereby increasing blood flow to my lady organs (as J tells me), or by simply forcing me to lie still and relax for an hour or so each week, or via the placebo effect. The scientist in me thinks the latter two mechanisms are more likely, even as the romantic in me (and the 20-year-old who studied abroad in the People’s Republic of China) would love to think that it might work via the former.

But frankly, I don’t really care why it might work; I’m just looking for it to work. Worst case scenario, I spend $75 per week for an hour of quiet relaxation.

 

p.s. If you want to read a different take on gay marriage and acupuncture, check out Stupid Stork’s latest post.

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Poor turnout

The ultrasound today did not go well. You may recall that when we saw 7 antral follicles at the baseline u/s, Dr. Y was careful to point out that

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

Well, at this point we’ve got two RSVPs – “Lefty,” the 14 mm lead follicle, and “Righty,” who is 11 mm. The other follicles are in there, but it seems they have other plans for Wednesday. So much for the virtues of estrogen- and androgen-priming…

Dr. Y said the chances of party crashers at this point is very very small. He said that he might be able to retrieve both big follicles…and that both might fertilize…and that both might grow into blasts.

He also said that there’s a good chance we could get nothing out in the end.

Our options, then, are to quit, convert to an IUI cycle (“so that at least you get something out of it”), or continue with IVF. It definitely seemed like Dr. Y thought the sensible thing would be to convert to an IUI. In that case, we would be refunded most of the $10K we paid last time, and could return the leftover meds for a restocking fee.

Ugh.

Since this was my first IVF appointment without C, I was trying to ask enough questions to be able to anticipate what C would want to know. Although I kept myself together, tears kept ‘leaking’ out of my eyes, and the poor nurse kept trying to pass me tissues.

I called C on my way out the door (he was on the way back from dropping friends at the airport) and we met a few minutes later at the beach. We sat on a bench and stared at the ocean and talked through the options. And we decided to move forward.

It’s probably stupid, but we thought we’d feel better knowing that we tried.

Will we feel ten thousand dollars better? I don’t know. But we both felt better knowing that we were moving ahead with the plan. We walked back to my car and I injected myself with my first dose of ganirelix. (No alcohol wipe or anything. Fuck it!) C also called Dr. Y and talked through our reasoning with him. He sounded good with it, once he was sufficiently convinced that we were informed and were comfortable with the cost.

So that’s where we are. The chances of success at this point are very slim. In the likely event that it doesn’t work out, we’ll probably pursue a second opinion and/or starting alternative therapy (acupuncture + supplements) to see if it helps with my responsiveness.

*****

I hope you’ll forgive me, but I’m feeling a bit deflated at the moment and not really in the mood to write a chemistry post about ganirelix. I may feel like it Monday, or maybe not.

Super sweet

How sweet! Aislinn at Ms Baby Makin, Ana at In My Garden Grow, My Eggtimer at The Egg Timer is About to Ring, and Lauren at On Fecund Thought (cutest IF blog name ever!) nominated me for a Super Sweet Blogging award. I’m so flattered!

I apologize that it took me so long to accept and pass along the love. (Don’t worry, this chain letter isn’t accompanied by a threat of 7 years of bad luck!)  In any case, I decided to accept this excuse to lavish praise on some great bloggers.

Conditions for accepting the award:

Thank the person who nominated you. Thanks so much Aislinn, Ana, Eggtimer and Lauren!

 •Answer 5 super sweet questions:

  1. Cookies or cake? Is cheese not an option? If not, then cake. Preferably made from a box (with pudding in the mix, yum). My favorite flavors are “yellow” and “cherry chip”…with – you guessed it – cream cheese frosting.
  2. Chocolate or vanilla? Vanilla. I know I’m weird, but I am not a huge chocolate fan. I’ll eat white chocolate or very dark chocolate (70% cacao or higher). In particular, Lindt truffles with the white or black wrappers are great! Milk chocolate is totally gross. Especially Hershey’s milk chocolate. Yuck!
  3. Favorite sweet treat? I’m not a big sweets person. I’d choose potato chips over candy hands down. But if I must choose, my favorite sweet treat is probably the aforementioned Lindt truffles…
  4. When do you crave sweet things the most? Sometimes after church I crave a glazed doughnut.
  5. Sweet nickname?  My mom used to call me Suga Buga. I think she meant it affectionately, but it sounds kind of weird now that I think about it – like I pick my nose and eat it so much, my boogers must have sugar in them? Maybe this is why I’m not such a sweet tooth…

 •Include the Super Sweet Blogging award image in the blog post:

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•Nominate 12 other bloggers. Here goes:

I’ll sort them based on what I like about them. I’ve also marked the blogs that talk about pregnancy or parenting with an asterisk, to avoid any surprises!

Fellow scientist (or pro-science medical professional) bloggers:

1. Ana at In My Garden Grow is an immunologist who illustrates her blog with these awesome colored pencil drawings. Okay, so she nominated me, but the rules didn’t technically say ‘no pingbacks’, and she’s a scientist. I couldn’t help myself. (Tag, you’re it again!)

2. Jenny at A Natural Scientist* is a PhD natural scientist of some sort (the few hints I can find point to biotechnology – which narrows it down NOT. AT. ALL.) Jenny ultimately made the brave choice to step out of the lab to be a full-time mom…and to blog about it.

3. Catwoman73 at Two Adults One Child* is a respiratory therapist who struggled with secondary infertility. Catwoman loves chemistry, ergo I love Catwoman.

4. Jane at Mine to Command is a medical professional (with a chemist husband) who has awesome taste in TV shows and movies, which she cleverly peppers into her blog (pay attention to the fictional names she uses for the characters in her stories!)

Inspirational bloggers:

5. TracySue at Journey to Somewhere*. Okay, so she’s actually not blogging anymore (at least not at this site), but she is an endocrinologist friend of a friend (though we’ve never met) who chronicled her experience with IVF. I read her blog from beginning to end as I was starting this journey. With her cute POAS “experiments” and scientific explanations, TracySue inspired me to start this little blog.

6. Jen at Overworked Ovaries* is a fellow DOR-sufferer, who writes one hilarious blog…and is pregnant with twins! Yay!

7. luvnmysailor at The Road to Minimart* is my first Protocol Buddy. I met her through the online forum for my local Resolve support group. She used my weird protocol to the letter. And got pregnant. Yay!

Sweet bloggers:

8. MrsDJRass at Baby Baby Please! is super sweet and a generous commenter. She had a BFN today and could use some words of encouragement!

9. Fertility Doll is sweet, funny, interesting, open, and – most of all – authentic.

10. elaaisa at Childless in Paris writes a poignant and sweet blog, interspersed with charming anecdotes about life amongst the Frenchies. (She’s Italian.)

Generally hilarious bloggers:

11. Aramis at It Only Takes One is in the DOR club. She also writes a brilliantly funny blog which I read from beginning to end in a day. (I couldn’t stop reading!)

12. Jenny at Stupid Stork! is an alchemist who takes the giant pile of shit that infertility gives her, and transforms it to shining gems of side-splitting humor, week after week.

*****

I was going to add a blurb about dexamethasone at the end here, but the story is turning out to be more complicated than I originally thought, and I barely have enough time to shoot up some nun pee before The Bachelorette starts … So, I’ll save the chemistry lesson for next time. Later!

Inspiration…and testosterone

Since starting this little blog, I’ve enjoyed finding other bloggers to commiserate with. But in finding bloggy friends, I’ve done my best to avoid blogs of people who were already pregnant. (Exceptions include Vanessa at Yeah Science! – the name of her blog was just too tempting,  and JoJo at An Infertile Road, my very first follower, who got pregnant – on her first IUI! – while I was following her.) I avoided pregnant bloggers because I wanted to shield myself from having to think about pregnant women, a sentiment that Jenny at Dogs Aren’t Kids expressed so well in a recent post.

The problem with this strategy – at least for me – is that it didn’t leave much room for optimism. I loved that there was/is no shortage of support and excellent company in my misery…but I also found myself doubtful that treatment could work for me. I mean, it didn’t seem to have worked for any of my other bloggy friends, so who was I to expect that it would work for me?! (Another problem with this strategy is that it makes me a little bit afraid of actually getting pregnant – like this amazing support system will suddenly vaporize as all my new friends go running for the hills!)

Since my last post, I took advice from Kimberly at No Good Eggs and joined my local Resolve support group. I haven’t been to a meeting yet (the next one is November 19th), but I joined their online forum. On this forum I found inspiration in the form of a Protocol Buddy – someone who followed my weird IVF protocoland had the same baseline AFCand got pregnant! And she writes a blog! I am so encouraged!

Furthermore, this experience gave me the courage to face my fear of pregnant infertility bloggers, and I started reading Jen’s blog, Overworked Ovaries. (Jen’s name and cute avatar kept popping up in the comments section on all my favorite blogs, with hints that her infertility issues might be similar to mine.) I’m about halfway through reading her posts (oldest first), and I find it so exciting to read a story that I know has a happy ending! It’s also great to see that so many of her awesome bloggy friends haven’t abandoned her, but are following along and cheering her on through her pregnancy. And I can’t help but think this is what it’s about! This is what I want!

And I feel hopeful.

*****

Now, let’s talk about testosterone. But first, the disclaimer:

I am NOT an endocrinologist, or any kind of medical professional! This blog does NOT purport to offer medical advice, medical opinions, or recommendations. Please take this for what it is – the ramblings of an infertile woman trying to make sense of her complicated treatment protocol!

*****

Last night I applied my final Androderm patch. The night I applied my first patch, I noted first that it is weird looking. C calls it my third nipple.

ImageI wasn’t exactly sure how to apply it, so I checked the website. Clearly they are not marketing to women trying to get pregnant:

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I couldn’t help myself, and decided to check out the website for Estrace cream for comparison:

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I’ll leave it to cleverer folks than me to comment…

Anyway, I waited to write about the testosterone-priming until now, partly because I was hoping dreading expecting to observe some side effects. I observed none. This fact makes me a bit skeptical that this low-dose patch would actually do anything for a 200+ lb man with low sex drive. Then again, that’s not why I am taking it.

And why am I taking it?

From what I can tell, the use of androgens (broad term for male sex hormones including testosterone and DHEA) to treat infertility patients is pretty new, and pretty controversial. Most of the papers I read were written by physicians at the same few clinics. But I think the gist goes like this:

  • Recent studies suggest that Diminished Ovarian Reserve is a condition characterized by the reduced ability to make androgens (including testosterone). This correlation seems to be especially strong in younger DOR patients. (Interestingly, several of the papers contrast DOR with PCOS, a condition characterized by overproduction of androgens…)
  • Testosterone is produced in the ovaries, in ‘theca cells’. Testosterone from the theca cells enters the ‘granulosa cells’, where it is converted to estradiol. (You can read more about estradiol in this post.)Image
  • Granulosa cells are the cells that surround the developing follicles and help prep and develop the eggs for ovulation.

The thought is that in theory [insert head tilt and two-handed gesture] since DOR patients can’t make as much testosterone, supplementation (through a gel or patch, or indirectly by taking DHEA – a testosterone precursor), will stimulate the granulosa cells to do their thing and prep those eggs. This is supposed to “enhance follicle recruitment” (more eggs) and “promote follicle growth and development” (better eggs).

At least a few studies seem to support this theory, showing a greater number of large follicles and better overall pregnancy outcomes for DOR patients treated with androgens (versus untreated DOR patients).

*****

I start stims (Clomid 100 mg + Menopur 150 IU) tonight, so I guess we’ll see!

No follicle left behind

Last weekend, C & I went out with some local infertility survivor friends. (They conceived their daughter on their second IVF attempt). I was so excited to see them and ask for their advice and provider recommendations. They’ve been understandably busy with their little bundle of joy, and we hadn’t seen them since deciding to undergo IVF.

Early in our dinner, I was reminded of how different this journey is for each of us, when I started explaining my protocol to this friend and she interrupted me to offer some well-meaning advice,

“You just need to forget about all those stats and research and just believe that this is going to work!”

Um. Yeah.

C suppressed a laugh, and I quickly explained that, in fact, the only way I was going to make it through this was to read and research everything I could, because I like learning about stuff (especially stuff that, you know, matters this much…), because it gives me something I can do, and because by doing it I can regain some feeling of control.

To her credit, she quickly relented, “I forget. You’re such a scientist!” Yes, yes I am.

*****

So, after asking for your book suggestions and reading your comments (Thank you SO MUCH for those by the way!), I got inspired to make the leap from nonfiction books on infertility (which were too general to answer specific questions about my IVF protocol or my diminished ovarian reserve) to the primary medical literature. It’s a far cry from my area of expertise, but I’m doing my best to find answers to some of my most pressing questions… But before I continue with what I think I know, let me offer an important disclaimer:

I am NOT an endocrinologist, or any kind of medical professional! This blog does NOT purport to offer medical advice, medical opinions, or recommendations. Please take this for what it is – the ramblings of an infertile woman trying to make sense of her complicated treatment protocol!

*****

Now that I’ve got that out of the way, let’s talk about Estrace! I’m currently on day 16 of Estrace supplements. I take two tabs (4 mg total) each evening (and thanks to you bloggy friends, I make sure to silently thank Dr. Y each time for instructing me to take them orally. No smurf sex for me, thank you!)

As I’ve mentioned several times by now, Estrace is just estradiol (E2) – the most potent of the female sex hormones. So, why take estradiol?

Here’s what I think I know about E2:

1) Estradiol serves a similar purpose to that of birth control pills in traditional IVF cycles. That is, it suppresses pituitary signaling to keep levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) low. The idea here is to shut down ‘business as usual’, so that Dr. Y can take control of my hormones with the stims when he is ready.

I was confused by this at first, since in a lot of the hormone signaling diagrams that I got from Dr. Google, estrogens (including estradiol) are shown stimulating the pathway leading to FSH and LH (a so-called positive feedback effect). But upon further study, I learned that moderate levels of estrogens inhibit production of FSH and LH (a negative feedback effect), while high levels of estrogens (such as occur when there are a couple of big lead follicles spitting out estradiol) stimulate FSH and LH production. Endocrinology is weird (and cool…and confusing, but mostly weird).

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Here’s some data I collected with a fertility monitor stick that corroborates this claim:

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To fully appreciate the significance of this blank stick, you might check out this post about how the CBFM works. In brief, the absence of an LH line (left) shows that no LH is being detected, while the faint E2 line (right) shows the presence of ‘moderate’ circulating E2 levels… (In case you’re wondering, the monitor read ‘high’ fertility due to the estradiol; it doesn’t realize that I’m in the middle of an IVF cycle and won’t be ovulating normally this month…)

But why not just use BCPs like everybody else?

Apparently, it is thought that in some people,  the classic ‘long Lupron’ protocol with BCPs might lead to less responsive ovaries, suppressed ovarian function, and/or decreased egg yields. From what I can tell, this may be a particular concern for members of the DOR club (like me), who need all the ovarian function we can muster…

2) Estradiol helps make lots of EWCM. I can vouch for this side effect of the Estrace pills. However, this is irrelevant to my cycle, since we’re doing IVF. No sperm needs to travel through my cervix this month (via my sperm-friendly EWCM).

3) Estradiol helps to prep the uterine lining for implantation. (Progesterone plays a major role in this, but apparently E2 can help out.) This is also irrelevant for me right now, since we’ll be freezing any embryos and doing a frozen embryo transfer in August. (I’m interested to see if Estrace is part of my protocol for getting ready for the embryo transfer, though. If so, I’ll assume this is the reason.)

4) The most interesting – and from what I can tell, least certain – effect of estradiol is that it in theory (C does a great impression of Dr. Y gesturing with both hands as he tilts his head to the side and says “in theory,…”)

Anyway, in theory, estradiol promotes the gradual, coordinated growth of follicles, which hopefully will yield more, high quality embryos. We don’t want one or two show-off follicles running ahead of the pack. It’s sort of a “No follicle left behind” situation.

Here’s hoping it works!

Green light

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

Seeking book recommendations

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

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

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

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

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

So…what do you recommend?

Why my husband rocks!

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

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

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

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

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

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

“Price is not a factor in our decision.”

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

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

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

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

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

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

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

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

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

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

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

Old habits die hard

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

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

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

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

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

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

Still here?

So, the ClearBlue Fertility Monitor…

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

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

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

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

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

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

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

Image

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

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

Image

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

My colorful protocol

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

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

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

First, my calendar for May:

Image

And my calendar for June:

calendar a

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

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

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

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

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

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

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

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