Green light

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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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?

IUI cycle start

So despite C.’s valiant effort, we are definitely not pregnant. 😦

I suspected as much this morning, and it was confirmed during my ‘Menopur Teach Class’ (a required class for informed consent before medicated IUI).

Anyway, as I mentioned before, I needed to schedule a ‘baseline ultrasound’ during the first 3 days of my cycle if I wanted to do IUI this cycle. Since C. and I were already at the infertility clinic for the class, the staff at the clinic was very accommodating and got me in this afternoon for the ultrasound, and for the one-on-one session to teach us how to prep and administer the shots.

Because of the short notice, a different RE at the clinic – Dr. L. – performed the ultrasound. Upon entering her exam room and taking stock of the decor, C. and I appreciated what we assume is Dr. L’s subtle sense of humor:ImageUnfortunately, the decor was the highlight of the visit. Not that we didn’t like Dr. L – we did! But the ultrasound revealed even fewer antral follicles than last time – only 3. And Dr. L. was less equivocal than Dr. Y. Among other things, she said that I would probably hit menopause before age 40. 😦

But the ultrasound did not reveal any ovarian or uterine cysts, which was good news for moving ahead with medicated IUI, and we had our one-on-one meeting with the nurse. Starting on Saturday, I’ll be giving myself subcutaneous injections of Menopur every night, and when the doctor says it’s time, a one-time intramuscular HCG ‘trigger’ injection, which I very much hope C. will give me. I’m strangely proud to say that I gave my first shot today (just saline solution for practice), and it wasn’t so bad. C. (who loves to tease me for my fear of needles) was especially impressed!

Test results

First, another update: I picked up C. in San Jose last weekend and flew home to San Diego with him yesterday. The flight was uneventful (a bit of turbulence, but smooth landing), but he was pretty tuckered out from the trip. Nice to have him home, though. The doggies and I missed him!

Back to the IF world. Now that I’m firmly in the two-week wait, I don’t actually have any news, but figured this would be a good time to fill in some of the holes in my earlier posts…starting with my pre-HSG test results.

I won’t share C.’s sperm test results, for the simple reason that I don’t have the values. (Due to HIPAA or whatever, I never got a copy of the results.) I will say (again) that I hear they were awesome. The best our IF nurse has seen, or so she claimed. C. is happy to believe her, and so am I.

So below are the results of my tests:

1) Antral follicle count. At my first visit with Dr. Y., he performed a transvaginal ultrasound and counted the number of antral follicles (maturing pre-eggs, visible under ultrasound). The idea here is that you can’t actually count the number of eggs a woman has left, so you assume that the number of partially-mature eggs your RE can see under ultrasound will give some indication of how many immature eggs (which your RE can’t see) are there. In general, more antral follicles = good, with ‘normal’ (in other words, ‘fertile’) levels being 16-30. My antral follicle count = 5.

The remaining three are all tests of blood hormone levels, determined from a blood draw on day 3 of my menstrual cycle. The structures of these hormones are shown below:

Image

Now, despite what my dad said in pretty much every Christmas letter throughout six years of grad school, I am not a biochemist. I’m an organic chemist, which means that I love to look at little chemical structures like the one of estradiol above. I start to get uncomfortable looking at any molecules bigger than about 1000 atomic mass units. Forget about proteins and nucleic acids! Both AMH and FSH (discussed in detail below) are protein hormones, which means that they are long chains of amino acids (AMH is composed of 560 amino acids; FSH is smaller*). If I tried to draw them using the same style of line drawing as estradiol, the drawings would be ridiculously large, indicipherable, or both. Instead, biochemists like to use other representations, such as the ribbon drawings above. The space-filling model is a compromise that makes me a little less uncomfortable, because I can at least see that there are carbons and hydrogens and oxygens, etc. Anyway, back to the tests:

2) Anti-Mullerian hormone (AMH). AMH is named for its role in preventing the ‘default’ development of female plumbing (“Mullerian ducts”…like uterus, vagina, and fallopian tubes) in male embryos. Its significance for infertility testing arises because AMH is released by egg-associated cells (“granulosa cells”) in the ovary, and – like antral follicles – is used as an indirect measurement of how many eggs are left. So, high AMH (>1 ng/mL) = good; low AMH = bad. My AMH = 0.17 ng/mL.

3) Follicle-stimulating hormone (FSH). As the name suggests, FSH stimulates the development of follicles (i.e. eggs) in the ovaries. My RE describes it as being like the gasoline that revs up the engine and gets your ovaries to develop and drop an egg. In young, nubile women, it doesn’t take much FSH (“gas”) to get the egg to drop. In women approaching menopause, you have to push the pedal to the floor to get enough gas for the egg to drop. In other words, low FSH (<9 mIU/mL) = good; high FSH = bad. My FSH = 13.7 mIU/mL.

4. Estradiol (a type of estrogen) is the main female sex hormone. In terms of predicting fertility, estradiol behaves a bit like FSH, in that your body may produce higher levels of estradiol (turning up the gas) as the number of remaining eggs decreases. Moreover, estradiol suppresses FSH production, so someone who has low FSH might actually still be in trouble if high levels of estradiol are ‘masking’ what would otherwise be high FSH. For this reason, REs like Dr. Y. typically order FSH and estradiol tests together… I can’t seem to find ‘normal’ values for estradiol, but since my high FSH levels already indicate very low fertility, I don’t think it matters! My estradiol = 24.6 pg/mL.

A side note about units:

As a scientist, I find it a little strange that every medical test seems to have its own units of measure. A cynical explanation is that perhaps physicians aren’t big fans of scientific notation, and prefer to choose a unit of measure for each test that gives normal ranges with values from 0.1-100 or so…even if it means learning dozens of different units. A more generous explanation is that maybe each of these molecules are being detected in different ways, and the units used might be determined by the detection method and sensitivity.

Regardless of the reason, here’s my guide to units for the tests above:

  • mIU/mL (milli-International Units per milliliter of blood). From what I can tell, the ‘International Unit’ is a biologist’s invention. (Is my bias showing?) It’s sort of like an ‘effective concentration’ that doesn’t translate to anything that a chemist would understand as concentration (like molarity, molalilty, normality, ppm, ppb, mg/mL, % by volume, etc.)
  • ng/mL (nanograms/milliliter of blood) For non-scientist types, a nanogram is one billionth of a gram.
  • pg/mL (picograms/milliliter of blood) A picogram is one trillionth of a gram, or one thousandth of a nanogram.

*For more about the structure of FSH, see: https://infertilechemist.wordpress.com/2013/04/16/injections/