Plan D

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

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

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

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

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

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

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

Plan C: Medicated IUI with Menopur

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

Plan E: IVF with donor eggs

Plan F: Adoption

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

Plan H: No idea. Suggestions?

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On being Catholic and infertile

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I’m a practicing Roman Catholic. And so, when first faced with our infertility troubles, I made an effort to better understand the church’s stance. (I knew that the church does not approve of IVF, but why exactly? What about IUI? Hormone injections?) Fortunately, while exiting church one day, I spotted the above pamphlet for $0.50. I bought it, and here’s what I learned:

Catholic church-approved infertility treatments:

  • charting (also the only approved form of birth control; we Catholics call it Natural Family Planning or NFP)
  • ovulation test strips/monitors (POAS = not a sin)
  • most testing/evaluation procedures (see exception below)
  • drugs, hormones, suppositories (whether taken for the purpose of encouraging ovulation or supporting implantation or pregnancy)
  • corrective surgery

Unapproved infertility treatments:

  • Testing sperm obtained by masturbation (Yep, jerking off = still a no-no. As an intriguing side note, there are apparently Catholic church-approved ‘perforated condoms’ that can be used to collect semen samples during sex – the perforations are necessary to avoid violating church teaching about contraception. And, suddenly my mind jumps to a wildly inappropriate prank idea…Then, that thought is replaced by a mental image of showing up at Dr. Y’s office and handing him a dripping condom…)
  • IUI or any other form of artificial insemination
  • IVF (or ZIFT or GIFT…do people still do these?)

So, what are the underlying moral objections to these forms of treatment? What I learned in this little booklet didn’t come as much of a surprise. I’ll paraphrase:

  1. The purpose of sex is procreation, so any act that divorces the two is a sin.
  2. Life begins at conception, and any act that destroys life [even an embryo] is a sin.

Now I have to acknowledge that Catholic Church teaching is consistent. That first statement is the single reason why the church forbids masturbation, anal/oral/etc. sex, contraception, and gay sex – all of which represent sex without the possibility of procreation. Assisted reproductive technologies (including IUI, IVF, etc.) on the other hand represent procreation without sex.

It wasn’t hard for me to reject the first argument. In fact, I rejected that argument a long time ago. (Judging by the size of the average Catholic family these days, I think it’s safe to say most American and European Catholics reject that argument, whether consciously or not.) Specifically, I don’t believe that God would make gay people only to present them the unappealing choice between being celibate or a sinner. I also don’t believe that God would limit heterosexual couples to a contraceptive choice that forces one partner to choose between ignoring her hormonal urges each month or getting pregnant with her 12th child… (Incidentally, I was especially surprised a few years back to learn that my favorite Dominican priest, Fr. D. shares this concern!)

The second argument is more difficult for me, and I’ve managed to avoid it during the IUI process, but not if we move forward with IVF. This is the same argument for why the Catholic Church opposes abortion, an issue which I also struggle with – perhaps more so now that we are experiencing infertility. I’ll set aside abortion for now, but what do I think about the destruction of embryos as a result of IVF? If you had asked me a year ago, I would have given a totally lame answer:

“I think it’s great that many suffering from infertility will get to achieve their dream of pregnancy by IVF, but I wouldn’t go to those lengths.”

If pressed, I might have continued that it would seem like “such an extravagant use of resources just for the luxury of my own biological child.” That “there are so many unwanted children in need of homes,” and that “maybe it was God’s way of saying he had another plan for me.” Yup, I was one of those people. I can’t believe my good friend N. (who went through 3 or 4 fresh IVF cycles – I lost count – ultimately resulting in a gorgeous little boy) didn’t slap me across the face when I told her I’d never do IVF. I’ve since apologized for being such a hypocritical idiot!

So my feelings about IVF have changed. Did they change because now it’s me? Because now IVF is my best chance at a genetic child? Certainly that has something to do with it. But something else has changed too.

After a miscarriage at 9 weeks followed 10 months of infertility (not to mention another six failed pregnancies among close friends in that same time period), I just don’t think of embryos the same way. Before this whole experience, I think I easily could have viewed each sperm cell and each egg as a ‘potential baby’. Under the right conditions, they could fulfill their destiny and grow into a living breathing human being. [insert slight sarcasm here]

What is now apparent is that, even under the best conditions I can muster (cushy uterus, healthy & “relaxed” host, optimum timing, perfect super-sperm), I’ll be lucky to get one of my eggs to reach its so-called ‘potential’. And the best chance of doing so is through IVF.

So how can I view the demise of 3- or 5-day-old embryos (assuming I’m lucky enough to get any) as ‘destroying a life’, when they almost certainly would never have existed without IVF, and when we are actively doing everything in our power to help them develop into a baby?

Frankly, I can’t (or won’t) see IVF that way. At least not now. And as a Roman Catholic, I’m okay with that!

Postscript: To those who would call me a ‘Cafeteria Catholic’

I know you’re out there; people who will accuse me of being a ‘Cafeteria Catholic’ or ‘CINO’ (Catholic-In-Name-Only), or what have you. Aside from trotting out my Catholic credentials (baptized, confirmed, and married in the church; attend mass weekly and on all holy days of obligation – including while traveling; fast and abstain during lent; confirmation sponsor to my sister; selected by the priest to serve on my church’s Pastoral Council; etc.), and getting angry (man that term irritates me!), I like to point out two observations:

  1. Everyone I’ve ever heard accuse someone of being a ‘Cafeteria Catholic’ is, by their own definition, a Cafeteria Catholic. It’s hard not to be. The Catholic Church – more than any other church – has an official opinion on just about everything. To not be a Cafeteria Catholic, someone would first have to take the time to learn everything that the Catholic Church teaches, and then take on the Herculean task of adhering to that teaching. Actually, to spot the hypocrisy involved in this accusation, you typically don’t even have to work that hard. Pick an issue outside of Catholic moral teaching (better yet, just pick something outside of the small subtopic of sexual morality) and ask the accuser how they live that teaching in their own life. Almost invariably, users of the term Cafeteria Catholic totally ignore some or all tenets of Catholic teaching on social justice, stewardship of the environment, capital punishment, just war, and so on. (For some reason, these folks seem to be obsessed with sex. Maybe they are angry that they’re not having enough …and are envious of everyone that is.)
  2. The use of the term ‘Cafeteria Catholic’ betrays an utter misunderstanding of where Church teaching comes from. Catholic Church teaching is not static. In fact, one of the things about it that so many fundamentalist Christians find objectionable is that we don’t believe the bible to be the final and supreme word of God. Instead, we believe that God continues to speak through an ever-growing Church tradition. New issues (moral and otherwise) arise, and the Church responds, typically by enlisting a panel of experts and church leaders, who engage in extensive discussions, and prayer, and ultimately arrive at some kind of consensus that is adopted as the official Church teaching. Thoughtful and prayerful consideration of issues is part of the process. Consistent with that tradition, priests are NOT mindless drones that regurgitate official Church teaching. The majority are highly educated critical thinkers, taught to ask challenging questions and grow in their faith through independent thought and prayer. Why should laypeople behave any differently?

If I disagree with American policy (or even a small subset of American policy), am I a ‘Cafeteria American’? Can I be a ‘Cafeteria Chemist’? The Catholic Church is losing enough believers as it is. Do we really want to be in the business of telling people they don’t belong?

I don’t mean to imply that the Church is ‘wrong’ about infertility treatment, and that my beliefs are ‘right’. I fully recognize that my knowledge and experience is inherently limited, that God’s plan is beyond my comprehension in this life. But I also feel confident that I am thoughtfully and prayerfully considering the consequences of my infertility treatment, and as of today, I am comfortable proceeding with IVF if this IUI cycle fails…

Optimistic

I’ve been feeling optimistic all day that this month is our month. It’s kind of cool, because it’s the first I’ve felt optimistic in awhile. I hadn’t admitted it out loud, but ever since our diagnosis of diminished ovarian reserve, C. and I seemed to be moving toward acceptance of the fact that we would need donor eggs in order to get pregnant… Anyway, it’s probably just wishful thinking, but I’m going to enjoy this feeling, however short-lived it may be.

In that spirit, here’s my list of reasons to be optimistic that this will work:

  • I’ve been dutifully taking my baby aspirin, CoQ10 (1200 mg), fish oil (1000mg), prenatal vitamins, and calcium (presumably upping the odds of nice, healthy, energetic eggs).
  • I’m on progesterone suppositories (that should help make a cushy uterine lining for my eggs to burrow into).
  • Despite his pain meds, C. gave an awesome sperm sample for the turkey basting (78 million swimmers, concentrated down to 30 million ‘winners’ who were direct-injected into the back of my uterus).
  • My plumbing got a good flushing during the HSG last month (only supposed to make a slight difference the month it happens, but as long as I’m being optimistic, I’m going to allow the possibility of a residual effect this month.)
  • Thanks to the injections, we had two good-looking eggs that presumably dropped (doubling the odds that one might actually be good relative to any other month).
  • The turkey baster – plus a bonus low-tech deposit the day after – should guarantee that there were swimmers around to welcome the eggs when they dropped.
  • I am 34. (Doctor said better to have my crappy hormone levels and be 34, than have my crappy hormone levels and be 42…even though my crappy hormone levels at 42 would make me more normal…)
  • I’ve cut back on coffee (<= 1 caffeinated cup per day) and alcohol (only one small glass since basting).
  • I’ve been uncharacteristically relaxed for this time in the school year (since C.’s accident, I’ve been accepting help from anyone who offered, and unafraid to say ‘no’ to annoying requests!)
  • C. and I are closer than ever, and I’m more convinced than ever that we would make fantastic parents.
  • I’ve been stocking up on ‘baby karma points’ by helping out a fertile friend on days when her husband is unavailable. I watch her baby girl (born just a couple weeks after the due date for our ill-fated pregnancy) while she puts her energetic 3-year old to bed.
  • Surely there must be some people who get pregnant on their first IUI (15-20%, if Dr. Google is correct), why not us?
  • I am just getting the hang of this whole infertility blogging thing, and will lose all my ‘street cred’ as an infertile if I get pregnant on the first IUI! (Does reverse psychology work on embryos?)

So there you have it! This could be our month. Fingers crossed!

Side effects?

Today was my last class of the semester (hooray!) So now I just have to finish some grading, administer the final (a standardized, multiple choice exam – double hooray!), and get ready for summer research, which starts on the Monday after finals (boo!). I am advising five undergraduates this summer, so I won’t get to take it easy, but they say a change is as good as a break, right? And the summer research schedule is definitely more flexible than the semester, so if we need to move forward with fertility treatments, it should be relatively convenient to do so in the summer…

In other news, I think I might be experiencing side effects from the progesterone suppositories. For the last two nights, I’ve slept poorly (waking up in the wee hours, with difficulty getting back to sleep), and last night had the most disturbing dreams! (Okay, so one likely contributor is the fact that I’ve been watching Burn Notice Season 6 right before bed – that show really took a dark turn this season – but still!) In one dream, I was a fugitive being chased by a CIA operative (definitely Burn Notice-influenced), and hiding – naked for some reason – in a little cave. Just when I was about to be discovered, I woke up in a panic. In the more disturbing dream, my sweet little pug – Winston – was in some kind of accident that caused his entire body to be severed. 😦 He was still alive, but it was such a gory scene, and he was obviously about to die any second. I was inconsolable.

Thankfully, I woke up to find my two fur babies sleeping peacefully:

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I am not looking forward to seeing what the next few nights have in store!

Injections

After three days of injections, I can honestly say that they’re not that bad. C. seems genuinely impressed at how comfortable I’ve become with it. He also seems to enjoy making references to “sticking me” whenever he can…

So, what is it that I’m sticking myself with each evening?

So far, it’s been Menopur, a combination of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) purified from the urine of postmenopausal women. (Since menopause may not be that far off for me, I’ve got it on my ‘to do’ list to find out how to donate my pee to the cause!) Anyway, the idea here is that both LH and FSH work together to stimulate my ovaries to develop pre-eggs (“follicles”). At the right dose, we can hopefully get my ovaries to prep 2 or 3 eggs. They’ll be monitoring me closely by ultrasound to see if that’s what is happening.

Then, when they give me the go-ahead, C. will inject me with a megadose of (generic) human chorionic gonadotropin (hCG) to trigger my ovaries to drop all the mature eggs at once. That way, when we do IUI (intrauterine insemination, aka the turkey baster), the chances are better of getting at least one “good” egg, and a successful pregnancy. (Of course, this also increases the chance of twins, but at this point, twins sounds a lot better than childlessness, so we’re not going to let that stop us!)

hormones 2

Structurally, FSH, LH, and hCG are all related. They are all dimeric glycoproteins (composed of two separate protein pieces, each with sugars attached). One of the protein pieces (the “alpha subunit”) is the same for all three hormones. What differentiates them from one another is the other protein piece (the “beta subunit”).

The beta subunits of hCG and LH are highly similar, and both proteins bind the same receptor. Here are some fun facts that result from this similarity:

  • I don’t feel too bad about the fact that I couldn’t find an image of LH for the figure above. Just put your nose up to the screen and cross your eyes to see two of the hCG structures – that’s pretty much what LH should look like anyway!
  • When C. gives me the trigger injection of hCG, we’ll be technically using hCG as a stand-in for LH, since LH is what normally triggers ovulation. Unfortunately, I can’t seem to find a good explanation why hCG is preferred for this use…
  • You can use an ovulation predictor kit (OPK, which measures the natural LH surge that triggers ovulation) as a poor-man’s home pregnancy test (HPT). The hCG produced by a fertilized egg is similar enough to LH to get a positive test. Don’t believe me? See: http://tracysue.wordpress.com/2012/04/25/experiments/
  • A corollary of that last fact: after getting my trigger injection of hCG, I would test positive on an HPT. I haven’t decided yet if the thrill of seeing a false positive test is worth the expense of the test, but if I do, I’ll post the test (and freak out any sporadic readers…mua-ha-HA)!

And this brings me to why everyone should prefer OChem over biochem. Small molecule drugs (like aspirin, tetracyline and Clomid – the realm of organic chemists) can often be taken in pill form, while protein drugs (like insulin, Menopur and hCG) pretty much never can. This is because the delicate three-dimensional shape of proteins doesn’t hold up well in the stomach (amid all that hydrochloric acid and digestive enzymes), and because their size (~30,000 amu for FSH, LH, and hCG, versus 405 amu for Clomid) makes it hard for them to get absorbed through the intestine and into the bloodstream. On the other hand, Clomid doesn’t work nearly as well as Menopur and hCG do, so perhaps I should wait to condemn the biochemists…

Anyway, tomorrow I’ve got an estradiol blood test and ultrasound to see whether the injections are working. Stay tuned…

The bottom line

After writing that last post, I realized that I had omitted any sort of conclusion from all that data. I started to edit it to fix the problem, and then stopped – that post was too long anyway – and decided my “diagnosis” was deserving of its own post!

So what is my diagnosis? According to my online medical records at kp.org, it’s “female infertility” – not vague at all! Of course, Dr. Y. never actually said that to my face. He said something more like “low ovarian reserve” (i.e. reduced number of remaining eggs). When talking to close friends and family, I prefer the technical term “ovaries of a 45-year-old”.

All joking aside, I’m not really sure what the results of all those tests actually mean. And, frankly, I’m not sure experts know what those test results mean… Dr. Y. was very cautious in his choice of words, and from what I’ve been able to read about it, I can see why.

What I know (or, what I think I know, based on what I’ve read in infertility books and online):

  • My test results are atypical for 34-year old women who have taken these tests (that is, women with infertility). They are more typical of women in their 40s who have taken these tests.
  • Women with low ovarian reserve (i.e. with test results like mine) tend to respond poorly to ovarian stimulation drugs. This means that IVF patients with this condition are less likely to produce lots of eggs at once (a prerequisite for IVF), and thus have higher rates of cancellation, and lower success rates overall for IVF.

What I don’t know (and, from what I can tell, nobody really knows):

  • What impact does low ovarian reserve have on women trying to conceive naturally (who only need to drop one egg at a time)?
  • What are the ranges of test values for women in the general population (that is, not just women experiencing infertility, which currently seems to be the only people this data is available for)?
  • How many eggs do I actually have left? (Or, put differently, how many years do I have until menopause?)
  • What is the quality of my remaining eggs?

As far as we know, I could still get pregnant naturally – after all, it happened once! Then again, 45-year old women get pregnant sometimes too…

So, why am I pursuing treatment, especially given that my test results seem to suggest that I am not the best candidate for IVF?

Two reasons:

  1. IVF is the ‘gold standard’ infertility treatment, offering C. and me the greatest chance for a biological child (still true despite my low ovarian reserve).
  2. Every month that we delay treatment, our odds of success with IVF go down (especially true given my low ovarian reserve).

For me, these two facts are enough to propel me forward, ignoring such ‘helpful’ advice as: ‘It’s in God’s Hands’ (Of course it is, but so is cancer; should folks not seek treatment for that?); ‘Just Wait, It’ll Happen’ (Wait for what? Menopause?); ‘Try this Diet/Potion/Lube’ (The fact that it worked for your sister-in-law’s aunt’s cousin’s daughter is so much more compelling than scientific data!); and the classic ‘Just relax!’ (Oh, why didn’t I think of that? [snapping fingers] I’m relaxed now!)

Actually, I don’t mind the well-meaning advice (for the most part), but that’s where we stand!

The try

First, an update: After 7 days in the hospital, C.’s risk of further internal bleeding was considered low enough to let him go home. The final tally (after hearing from a team of trauma surgeons, radiologists, and the like) was a bit worse than I said in my last post: 7 broken ribs, 3 broken vertebrae, class 4 lacerations on both liver and spleen, and a hemopneumothorax (blood and air in the chest cavity). Incredibly, he did not require surgery – just a few stitches on his knee, close monitoring for internal bleeding, and a $*#!load of painkillers (more on those later). Since he was in San Jose at the time of the accident, the ‘home’ that they released C. to is his parents’ house. Yesterday, I flew back to San Diego to return to work. The plan is for me to fly to San Jose again on Friday to pick up C. and bring him ‘home’ to San Diego…

But this blog is supposed to be about infertility. As I mentioned before, the timing of C.’s accident relative to my anticipated ovulation date made it unlikely that we would get to try this month. Well…I’ll spare you the details, but suffice it to say that there is at least the possibility (however remote) that I could get pregnant…(Nobody can accuse C. of not being dedicated to baby-making!)

Now whether that would be a good thing is another question entirely. In the past week, C. has been on a laundry-list of painkillers, most opiate narcotics. In the hospital, his drug of choice was hydromorphone (trade name Dilaudid), a fast-acting IV narcotic. Unfortunately, he couldn’t take that one home and had to settle for the ones that come in pill form, including time-release oxycodone (trade name OxyContin); a mixture of hydrocodone and paracetamol (trade name Norco); and ibuprofen (trade name Motrin). The narcotics are all derived from the natural products morphine and codeine, alkaloids produced by the opium poppy. For your viewing pleasure, I’ve pasted the chemical structures below.

If we do get pregnant this month, our baby might come out addicted to prescription painkillers!

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How we got here.

Hmm. How far back should I go?

I could start at the beginning… Once upon a time, there was a 21-year-old girl who loved school in general – and organic chemistry in particular – so much that she left her college boyfriend to move out to the east coast to go to graduate school. She didn’t worry about having kids yet. After all, she was only 21 years old, and would have plenty of time once her career was on track…

Hmm. Maybe that’s too early to start. How about when we started trying to get pregnant… After getting married last January, and recognizing that we wanted more than one kid and that we weren’t getting any younger, we started trying to get pregnant in early March. In month 1, this just meant ‘pulling the goalie’ and going for it. The next month we tried to time it starting around day 10 and continuing for about a week straight. The third month, a friend gave me her copy of ‘Taking Charge of Your Fertility’ by Toni Weschler. I read it in a couple days and figured out what we were actually supposed to be doing… We got pregnant that month, in my first attempt at charting.

Everything was great. We went on our perfect little honeymoon to Ireland (which we had put off due to my work schedule), where I restricted myself to the hard Irish cheeses, and only the tiniest sips of Guinness and Irish whisky. We came back and went to our 8 week appointment the next week, only to see that there was no heartbeat. The baby had stopped growing at 5 1/2 weeks…

But we were okay. We had gotten pregnant once. We knew that I was ovulating, that nothing was blocked, that his swimmers could swim,… Fast forward to December. By that point, we had had several cycles in which we timed things perfectly and no pregnancy. By this point, I’d read enough books about infertility to know not to put off seeing a specialist. So we made an appointment in January with the Kaiser Reproductive Endocrinologist.

And what now? After the standard tests, we know that C. is superman. (The nurse literally said his sperm test results were the ‘best she had ever seen’.) And at the ripe old age of 34, I apparently have the ovaries of a 45-year-old woman…

So we’re moving ahead with medicated intrauterine insemination (IUI, aka ‘the turkey baster’) next month, and probably in-vitro fertilization (IVF) after that. This month we have ‘homework’ to get ready for IUI, including a hysterosalpingogram (HSG, more about that later), and a 2-hour class on how to give myself hormone shots. Add another notch to the tally of stuff-I-never-wanted-to-know.

Tomorrow I take a blood pregnancy test (spoiler alert: I’m not pregnant) and pick up a prescription for antibiotics. Both are required before they’ll do the HSG on Thursday. Will let you know how it goes!

Here goes!

A few weeks ago, after getting the diagnosis of “female infertility” and confronting a variety of painful emotions, a friend of mine suggested that I read her friend’s infertility blog (http://tracysue.wordpress.com/). I did, and it was awesome.

And then, after deciding to move forward with treatment, I felt inspired to write my own little blog… I think a blog will have the benefits of:

  • keeping close family and friends up-to-date without having to tell the same sordid details over and over
  • providing an outlet for my ever growing trove of information-that-I-never-wanted-to-know about infertility
  • serve as a first step in helping me get connected up with the online community of IF-ers like me
  • provide inspiration/consolation/comiseration/some other-ation to someone else struggling with this

Okay, so the last two are probably optimistic, but maybe… Anyway, I’m hoping the benefits will outweigh the costs of this blog – namely, time. (Ahem, that is, time I should be spending prepping lectures, grading, cooking, cleaning up, shopping, reading, hanging out with my dogs and  husband, or countless other things…or so says the little voice in my head.)

Anyway, I’m choosing to ignore the little voice and give it a try. Here goes!