Turkey baster day!

Today, C. and I went in to the clinic to get this turkey basted (that is, for intrauterine insemination or IUI). Here’s what was involved:

  1. C. prepared his sample right before we left for the clinic, then kept it warm in his pocket during our drive. (It takes a half hour for it to ‘liquefy’ prior to washing.)
  2. We arrived at the clinic and waited. This part was long enough to stress us out a bit, since the specimen is supposed to be processed within an hour.
  3. Once in the back, we handed over the sample to the nurse and signed a form stating that it was indeed from C.
  4. We waited again, this time for the doctor (Dr. H.) to ‘wash’ the sperm. More about that in a minute…
  5. Dr. H. came in, and confirmed again that the sample was indeed from C. (After being asked again, we started to actually worry! What if our sample got mixed up with one of the people in the waiting room?…) She complemented C. on his excellent sample. (She counted 78 million sperm per milliliter upon arrival, and 30 million ‘good swimmers’ that made it through the washing procedure and to the final sample. This raised our confidence that they were actually C.’s! ๐Ÿ˜‰ ) Then she explained what was going to happen.
  6. The next part started like a pap smear: me in stirrups, mildly uncomfortable; doctor inserted speculum then swabbed my cervix with a big Q-tip… Then out came the turkey baster! (Actually it looked more like a syringe with a little tube…)
  7. After the basting was done, Dr. H. tilted the bed back and left me there for ~30 minutes to let gravity help the little guys along.
  8. She reiterated the advice to BD tomorrow, just to be sure. And that was it!

The whole thing really wasn’t bad! No cramping at all. (Dr. H. told me I have a ‘quiet uterus’. I guess that makes sense; they’ve had two geriatric ovaries for neighbors this whole time…)

The sperm washing part was interesting to me, since it involves organic chemistry. ๐Ÿ™‚ So, why wash sperm?

Aside from the high quality ‘Michael Phelps’ sperm cells, semen also contains slower-moving or dysfunctional sperm, prostaglandins, and bacteria (ew!) The cervix normally acts as a natural ‘qualifying round’ to keep out everybody except those super-swimmers. Since IUI bypasses the cervix, another gatekeeper is needed – hence the sperm ‘washing’.

Here’s the chemical structure of the two major prostaglandins in semen. Prostaglandins are made from fatty acids (hence the long chains on the right side), and always have a five-membered ring.

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Prostaglandins stimulate muscle contractions, which might be good when you’re trying to help sperm get into the uterus (or if you’re 42 weeks pregnant and trying to induce labor – not exactly something I’ve had to worry about…), but if inserted directly into the uterus, the prostaglandins can cause severe cramping, vomiting, fever, and diarrhea. Not so nice.

The next step for me is a progesterone blood test on Wednesday, followed by progesterone suppositories to support a pregnancy (in case there is one!)

Ever the pessimists, we also scheduled an IVF consultation with Dr. Y. so that we have a clear idea of our options if this doesn’t work. Hopefully we won’t need it!

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Trigger shot

I had my estradiol and follicles checked today. Two looked like they could drop any minute, so the nurse practitioner – D. – administered the hCG trigger shot while I was there. (Poor C. didn’t get to “stick me” after all!)

For all the data monkeys (like me) out there, here’s a summary of my test results:

Estradiol (E2):

  • baseline estradiol (taken during infertility workup 1/26) = 25 pg/mL
  • estradiol on 4/17 (after 4 days of injections) = 281 pg/mL
  • estradiol today (4/19, after 6 days of injections) = 572 pg/mL

According to this FAQ (http://www.fertilityplus.com/faq/iui.html), the target is 200-600 pg/mL per big follicle; since I only have two big follicles, I think this means I’m good.

Follicle size & count:

  • On Wednesday (4/17) I had three visible follicles, measuring 14.5 mm, 13 mm, and 11 mm.
  • Today (4/19) the same follicles measured 18.5 mm, 16.6 mm, and 11.5 mm. Below is a picture of my biggest follicle, viewed on ultrasound. (The follicle is the black oval just left of center with the dotted cross through it). 18.5 millimeters sounded huge to me, so I posed a penny (also 18.5 mm in diameter) in the photo for reference!

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According to that same FAQ above, it looks like 16-18 mm is a good range for Menopur-stimulated follicles, which is consistent with what nurse D. said. She expects that the smaller one will probably not release, so we’re looking at two follicles this cycle.

Things are slightly less than ideal. For our best chances of pregnancy, our target would have been 3-4 big follicles (to increase the odds of at least one ‘good’ egg taking). But 2 is better than 1, and better than 5+ (in which case we would’ve had to cancel the cycle or risk a multiple pregnancy). In addition, it would have been better to inseminate 36 hours after the trigger shot, but since the clinic is closed on Sunday, 24 hours will have to do! Nurse D. pointed out that it’s better to inseminate early than late, since the sperm can “wait for the egg”, while the egg can’t do the same. (I’m sure there’s a sexist joke to be made there…) She also suggested BDing on Sunday to be sure…

So I’ll be back tomorrow for the insemination. Wish me luck!

Looking good!

So today I had a blood estradiol (E2) test, and ultrasound to see how I’m responding to the Menopur, and all looks good. ๐Ÿ™‚

The annoying part is that they only do the estradiol test at the hospital lab across town, and only from 7-7:30 am. So I had to wake up at 5:30 this morning to get ready and drive east to the hospital, and then drive back west in rush-hour traffic to teach my 8:30 class. Fortunately, the infertility clinic is on this side of town, so making it to my 10:30 ultrasound appointment was no problem.

Anyway, the result is that I have two decent-sized follicles, and one smaller one. This is good news, since our target is 2-3 follicles for IUI. Based on the size of the follicles and on my estradiol (281 pg/mL), the nurse practitioner recommended upping my dose of Menopur from 300 IU to 375 IU per injection, and repeating the blood draw (5:30 am wakeup – Boo!) and ultrasound on Friday. Depending on those results, we may do the insemination as early as Saturday!

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 โ€œbeta subunitโ€).

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…

One-woman pharmacy

I went to pick up my drugs for medicated IUI yesterday. Annoyingly, the Kaiser pharmacy at the infertility clinic was out of Menopur – the clinic’s most-prescribed infertility drug – and I had to drive across town to the hospital pharmacy…only to find that they were out of needles?!

On the plus side, my insurance is evidently pretty good, and I got over $2K-worth of prescription drugs, syringes, and needles for $32! I wasn’t as lucky with the supplements Dr. L. recommended (including Coenzyme Q10, omega-3 fatty acids, and baby aspirin). Even with a buy-one-get-one-free sale at CVS, these cost me $134!

Here’s the loot:

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For the chemistry of these, I’ll start with the easy stuff (i.e. the small molecules)… Here are structures of the supplements Dr. L. recommended:

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Aspirin is the acetate of salicylic acid – a natural product from the bark of the willow tree. Coenzyme Q10 is a quinone (hence the Q), and an antioxidant. (The quinone part of CoQ10 is shown in blue above.) Omega-3 fatty acids are a class of fatty acids that contain multiple double bonds with the first double bond starting at carbon-3 (counting from the ‘omega’ end, or the left side on the structures above). Omega-3s are made by plants. People can get them by eating plants (especially the seeds), by eating fish (who in turn get them from eating algae and plankton…), or (in my case), by taking fish oil supplements.

Dr. L didn’t go into detail about the rationale, but said that she recommends these supplements to “maximize the quality” of my remaining eggs. From reading the labels, it looks like all are supposed to promote circulation, which I guess is a good thing for eggs. (Did I mention I’m not a biologist?) There’s also something psychologically satisfying about taking a bunch of pills…feels like I am doing something.

I’ll save the chemical structures of Menopur for another day, since it’s more biochemistry (yawn!); this post is already too long; and I’m hungry!

Wish me luck for my first Menopur injection tonight!

IUI cycle start

So despite C.’s valiant effort, we are definitely not pregnant. ๐Ÿ˜ฆ

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. ๐Ÿ˜ฆ

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!

Dr’s visit

Yesterday, I met with Dr. Y. for my HSG follow up visit. Highlights:

  • Dr. Y. expressed sincere concern for C.’s accident. (Love him!)
  • Dr. Y. expressed interest in seeing the image of my uterus from HSG that I have on my cell phone. (Even if he was faking, I don’t care. Still love him.)
  • Dr. Y. reassured me that while C.’s pain meds might reduce the odds of a pregnancy, in the event that I do get pregnant, there shouldn’t be any effect on the fetus. (One less thing to worry about.)
  • In the likely event that I don’t get pregnant, I need to call his office as soon as my period starts to schedule an ultrasound. (US has to happen within 3 days of my period start if I want to do IUI this cycle…one more thing to worry about!)
  • The rescheduled date for my menopur class (class to give myself hormone shots for medicated IUI) should hopefully happen before my period starts…if it doesn’t, then I won’t be able to do IUI this cycle. (Another thing to worry about!)

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!