I am writing you this letter because through many years and hundreds of conversations I still haven’t found a way to say to you what I need to say and think you need to hear. I don’t know why this is so hard for me, you would think that after all I have been through it would be easy for me to tell you not to wait, not to do what I did and let precious fertile years slip away. After hundreds of shots, tests, ultrasounds, and buckets of tears I should be screaming at you “Don’t wait! You can’t wait. The most fulfilling and beautiful experience a woman can have is slowly creeping out of your reach and you have to do something about it NOW.”
But I don’t do that. Somehow I can’t ever find the words, not matter how hard I try.
I have danced around the topic many times and I know you share my discomfort when I do. You tell me you will be okay either way. You can imagine a life with kids and can also see a life without and that either can be great. Like me, you went to school, experienced life, began a career that you loved, and haven’t felt like the time was right to have children. And of course you want to find that person, the one who makes you long to carry a child. I understand, life just hasn’t come together in the right way to make you a mother yet, or even to allow you to give it too much thought. It seems so distant, so impossible and foreign, even if you feel that natural drive pushing you toward doing what you were made to do.
I remember the feeling well. There was a time in my life I wasn’t even sure that I wanted children. And then at 34 I had a moment that changed that, a moment that many women have and that you too may have someday. The moment is different for us all and doesn’t happen for everyone, but it does happen for many women like us.
After that moment, all I wanted was to be pregnant and to give birth. So we started trying. I had no idea that I was about to wrestle with demons that, up until that time, I didn’t even know or care existed.
And how would I know those demons were waiting in the dark shadows of infertility when celebrities all around me were popping out babies in their mid-forties? I didn’t know then and chances are you don’t know now that there is a damn good chance that those babies carry the DNA of much younger women and are born of expensive, invasive, and emotionally difficult procedures.
Chances are you don’t know that fertility takes a nose dive at 32 and not at 35 like you have always heard. You heard that because long ago we only measured in 5 year increments but today we know more, a lot more, and we know that we are losing valuable time. Sadly, for most bright, ambitious, and driven women like you, your early thirties arrive before you are even the “you” that you want to be before you are ready to become two or especially three.
I am lucky and thankful every day that we started when we did. After multiple heart wrenching, physically taxing, financially draining, and emotionally painful procedures we had our little girl and I have never been the same. I am sure you are right, life without her could indeed be very good, but I have no doubt hat it is better with her. She is love, pain, joy, fear, purpose, and every human emotion in technicolor. I couldn’t breathe without her and I don’t even remember what mattered to me before her. I am smitten, turned upside down and inside out, and its wonderful.
I want that for you if you want it. And I want you to understand what you may need to do to get it, because if I don’t tell you I don’t know who will.
I am thankful every day that we started when we did, right at the peak of the steep slope of declining fertility. Four years later in our quest for a sibling, the fight is even harder and we are unsure if we will win it this time. Looking back, I wish I had created more young embryos and stored them before transferring the one that gave us our daughter. Or I wish we had made embryos right after we were married and put them on ice for awhile until we were ready to try for the first time.
Better yet, I wish I could talk to my 25 year old self and tell her to go through the slightly expensive but highly effective process of preserving her fertility through egg freezing.
Twenty-five year old me would have thought I was completely insane, because she had time and wasn’t even sure she wanted a baby. I know she would never have done it. Why spend all that time and energy on something she might not even need during a time in her life when she felt like she had way more time than money?
That’s the reaction I expect from you too and its the reason I haven’t said all this to you before. After all, I don’t like it when people tell me to “just relax” or give me other unsolicited advice about my fertility. Who am I to presume that you want or need to know this? Who am I to tell you that even if you aren’t ready you should talk to a specialist, get a few tests done, and consider your options for preserving your fertility even if you may never decide you want a child?
You may not need any of this. Fertility is different for everyone and some women can and do get pregnant in their late 30s and early forties, Its just not nearly as common as popular culture makes it seem. I want you to know that. I want you to make an educated decision about one of the most important and amazing choices we make as a woman.
I want you to know because I wish someone had been brave enough to tell me.
So who am I to say such things to you, Sarah?
I am a woman, mother, friend, and an advocate. But above all else I am someone who loves you.
All My Best and Love,
Alisa
*Image by William Arthur Fine Stationary via Flickr
Congratulations! You passed your final exam in IVF 101 and now are ready to get into the details of the IVF process in IVF 102.
In IVF 101 we described all the players in the IVF game. The first and one of the most important members of your baby dream team is your Reproductive Endocrinologist (RE). His title alone should give you a bit of insight into what all this In Vitro business is all about. Note that your RE is not called “Chief Baby Maker In Charge.” He does not hold a specialized degree in “Getting People Knocked Up”.
Sure, the emphasis of his training is to figure out how to get you pregnant, but the job title alone is an indication that what he really does is try to get your endocrine system and all its hormones working together to set the stage for pregnancy. Your RE is essentially an endocrine system manipulator and he has a variety of ways to adjust your hormones and help you make a baby.
It is impossible to describe all the different ways he can do this in one simple post. Because each of us is unique, the plan your doctor will give you is tailored to your needs. I can’t possibly speak to your individual situation. However I can give you an overview of the basics of the stages involved in IVF.
Step One- The Human Pin Cushion
Think all your needle woes begin when you start taking your IVF medication? Think again. When you sign up for IVF you and your partner will go through a ridiculous amount of diagnostic testing. Even if you completed many tests with your OB/GYN before moving on up to the big time, you will likely do it again. For the mommy wannabe, the clinic will test various hormone levels to make sure they are in the proper range. Tests will also be done on the thyroid to ensure its functioning properly. The RE could decide to run a number of other labs to rule out the possibility of autoimmune issues, although this was not done for me until we had a couple of failed cycles on the books.
Image by Phillipa Willitts via Flickr
Some tests like the sonohysterogram or hysteroscopy don’t involve needles but still totally violate you and remove any remaining modesty you had prior to turning to IVF. These tests involve checking your uterine cavity and fallopian tubes to look for potential clues as to why embryos aren’t implanting for you.
Your spouse, partner or sperm donor will also provide a sperm sample to inspect that his part of the equation is doing its part.
Image by Gerda via Flickr
All involved parties will be tested for communicable diseases prior to beginning the first cycle. If you have experienced multiple IVF failures or miscarriages, or if one of you has a family history of genetic disorders, you may also receive karyotyping (genetic testing) to rule out problems based on how you and your partner’s genetic codes match up.
Finally, the RE will perform a mock embryo transfer in order to take note of the layout of the mama-to-be’s anatomy and measure exactly where an embryo should be placed at the actual transfer. A smooth transfer is a strong indicator of pregnancy and live birth rates. It’s better for the embryos and implantation if the RE has a road map with a path planned out before the embryos come back to you.
Step Two- Turn Out the Lights, The Party is About to Begin.
So you made it to step two? That’s something to celebrate because step one can throw some nasty curve balls capable of making Nolan Ryan’s jaw drop.
Once you are cleared for take-off the RE may find a way to shut down your natural hormones so he can take over and manipulate your cycle. That is if you are doing an agonist protocol.
Here is where things get hairy and the approach diverges based on the patient and clinic. There are two types of basic protocols. In an agonist protocol your doctor will shut down your pituitary gland or “down regulate” your hormones using a drug called lupron for 10 to 15 days prior to starting stimulation meds. For this reason, this protocol is often called a long lupron protocol. As the name suggests, this protocol takes a bit longer than the other protocols.
The other type of protocol is an antagonist protocol. It’s a much shorter process since there is no down regulation prior to starting stimulation medications. Instead, your doctor will protect against premature ovulation and control the speed of your response to stimulation meds using one of two antagonist medications on the market, Ganirelex or Cetrotide. They are the same thing produced under different brand names. These medications will be started on day four to day seven of stimulation.
In any protocol, the RE will often have some control over your cycle by placing you on birth control prior to the start of your cycle month. Not all clinics use birth control pills but most do these days to help bring a little bit of predictability to an otherwise unpredictable process.
Yes, it is ironic. If I had all the money I paid for birth control when I didn’t know I didn’t really need it I could almost pay for a full IVF cycle. Almost. But here we are taking birth control again in an attempt to get pregnant.
Go figure.
Lupron, Ganirelex, and Cetrotide are all subcutaneous injections (tiny thin needle injected into soft tissue). This means less pain at administration. Yay!
Step Three- Fueling the Baby Making Machine.
Sometime in the first few days of your menstrual cycle you will begin taking the most important and priciest of hormones in IVF, follicle stimulating hormone (FSH). The three main gonadotropin brands are Follistim, Gonal-F and Bravelle. Once again, they are essentially the same and marketed under different names.
Your treatment may include some form of Menotropin (hMG) instead of a gonadotropin or in combination with it. Menotropins contain both FSH and leutenizing hormone (LH) extracted from the urine of menopausal women. Not only is this gross, but it does make one wonder, “Who are these women and what do they get paid for this?”
Image by Angie via Flicke Apparently their urine is also pretty creative
Menopausal women have a lot of FSH in their urine because the hormone is no longer being used by their follicles and therefore passes right through their system. The difference between gonadotropins and menotropins is that the latter also contain (LH) which is found in Lupron and used to either suppress or start ovulation depending on the amount and timing.
Menotropins were the earliest form of stimulation medications and existed before the FSH only drugs (also called recombinant FSH) were created. There are many brands of menotropins but the main ones are Menopur, Repronex, and Pergonal. The first IVF baby was created using Pergonal. Many studies have been done comparing pure gonadotropins to menotropins and live birth rates are the same. Your doctor may combine gonadotropins and menotropins for low responders, those of us that need a lot of FSH to scream at their ovaries.
In a natural cycle, the FSH hormones kick off the development of multiple follicles in the ovaries. Each follicle holds an egg and in the beginning of your menstrual cycle many follicles begin to expand and grow.
However once one follicle is large enough to begin producing an ample amount of estrogen (8 to 10 mm), the estrogen being produced by the follicles builds up and sends a signal that causes the body to decrease the FSH. The decrease in FSH has the effect of quieting the rest of the follicles and leaving only the one dominant follicle to continue to grow and mature. In the case of fraternal twins, two follicles continue to grow and release eggs.
Unlike a natural cycle, in an IVF cycle we add greater amounts of FSH and keep the level consistently high in order to “recruit” as many of these follicles as possible to grow and fully mature. This will give the infertile patient many eggs instead of the one that would typically be released naturally, allowing the couple many opportunities at a healthy baby from only one cycle month.
FSH essentially tells your ovaries “Hey, let’s grow some follicles!”. For some women, all they need is a whisper from FSH to get a response because receptors in their follicles are very reactive and “hear” the FSH well. Others need a lot of FSH to scream “HEY LET’S GROW SOME FLIPPIN’ FOLLICLES ALREADY!!!” at their ovaries in order to get things going.
Image by Danny via Flickr
This can cause the cost of drugs to vary a great deal and is also the reason you may find your RE will increase or decrease your meds after monitoring your blood work and ultrasounds. Making adjustments isn’t a good or bad thing, your doctor is conducting a symphony of hormones and feels like the sound needs to be adjusted to make the beautiful music of pregnancy.
Like the antagonists, all hormones used in this stage of the process are typically injected subcutaneously. Double yay!
The stimulation part of the process can take as few as six days to more than 20 in poor responders. However most women take stimulation medications for around 10 days. You will be monitored every two to three days to assess size of your ovaries, your follicles, estradiol levels, and also to guard against hyper stimulation which can be dangerous. Your RE will also be looking for a nice thick uterine lining with a clear triple layer pattern. Most clinics like to see the lining at at least 7mm prior to retrieval.
Once you have follicles measuring at least 18mm-20mm and your estrogen is in the right range, its time to trigger ovulation. At this stage you will also likely be visibly bloated, uncomfortable, and ready to have the follicles aspirated in order to get some relief.
Step Four- Grow the Heck Up and Get Out of Here Eggs!
In the last few days of stimulation, you may be monitored daily. This is because timing of the trigger shot it crucial. If you trigger too early, the eggs may not be mature. Too late, the eggs may degenerate. The trigger causes the final stage of maturation, meiosis of the egg.
Meiosis is a process where the egg divides its 46 chromosomes into 23 that will pair up with 23 from the sperm. Failure to divide properly is common and increases with age, which is why fertility declines and chromosomal abnormalities increase as a woman gets older. To put it simply, your eggs get “stickier” as they get older and don’t divide as efficiently, leaving extra or not enough chromosomes at the end of the division process. Most of these eggs will simply fail to fertilize or the embryos will arrest early in the development process. Some can implant and lead to miscarriage, and in rare instances abnormal embryos can grow to be a baby with Trisomy 18 or Downs Syndrome. So this stage is critical.
Without retrieval, ovulation would occur 38 to 42 hours from trigger. Your retrieval will be scheduled right around the 36 hour mark to allow your eggs to be as mature as possible before collection.
It is at this stage that 10 to 20% of cycles are cancelled, usually due to a small number of follicles and/or low estrogen levels. In extraordinarily rare instances a patient may ovulate prior to retrieval which would also cancel the cycle. Even though it is extraordinarily rare, you may be like me and totally freak out about possibly ovulating early for every waking second of those 36 hours. Don’t be like me. It is very unlikely you will ovulate.
Once upon a time there was only one way to trigger ovulation and that was with an intramuscular injection of Human Chorionic Gonadotropin (HCG). Today some clinics trigger with lupron or a combination of HCG and lupron. Typically lupron is used when estradiol levels are very high to decrease the risk of ovarian hyper stimulation syndrome (OHSS). There is some evidence that the HCG trigger is superior, but doctors are learning more and more every day about how to improve the effectiveness of the Lupron or combination HCG/Lupron trigger.
The HCG trigger shot is typically the first of your intramuscular injections (crazy long and thick needle injected into the upper outer quadrant of the buttocks). Ouch!
Image by Gerda via Flickr
Step Five- Your Own Personal Easter Egg Hunt
Now it is time for your RE to go in and get the eggs you have worked so hard to create. Generally, your partner or donor will provide his part of the equation right before or during retrieval so his little swimmers are ready once your eggs are retrieved. He will often be given the choice to collect at home or schedule an appointment to collect at the office.
Image by ntr23 via Flickr
Retrieval is the most invasive and difficult part of the process. You will be sedated during retrieval. Some doctors will put you all the way under, while others use twilight anesthesia. I have experienced both and prefer twilight anesthesia despite the fact there is still a fair amount of discomfort. Even though you are loopy under the anesthesia, its pretty nifty to experience the procedure. Plus at my clinic you hear the egg count as the embryologist reports it back to the doctor as retrieval is happening.
Who doesn’t love immediate gratification?
The RE retrieves the eggs by piercing the vaginal wall with a needle on the end of a special ultrasound probe. The doctor carefully inserts the needle into each follicle and drains the fluid, including the egg. This process takes anywhere from 15 to 30 minutes depending on the number of follicles. Your vitals will be monitored for at least an hour after surgery and you will need someone to drive you home. Because the meds stay in your system, you will need a full day off from work but can plan to return the next day. You will be uncomfortable for a day or two and can take acetaminophen to help with the pain.
Every follicle contains an egg or else it wouldn’t exist, however some women retrieve fewer eggs than the number of follicles seen on an ultrasound. These women are often told some follicles were “empty”. That is not the case. What really happened was the egg was simply not ready to come out of the follicle. The trigger not only starts meiosis, it also loosens the egg from the follicle wall. When this does not occur, it is impossible to remove the egg from the follicle. Even if it could be removed, this egg would not yield a healthy embyro. Timing of the trigger is one possible explanation for this, as well as general egg quality.
After retrieval you will begin taking a few other medications which vary based on patient and clinic, but you will definitely take an antibiotic of some sort and an anti-inflammatory. If you are doing a fresh transfer, you will also start progesterone supplementation on the day of retrieval to prepare your lining to receive your embryos in three to five days.
There are many ways to take progesterone including vaginal suppositories (both gel and tablet) as well as painful intramuscular injections. Many doctors prefer the injections until after pregnancy is established to avoid uterine contractions during the implantation period. Progesterone supplementation will continue until around 10 weeks when the placenta takes over its production.
Step 6- It’s Baby Making Time
Once the eggs are harvested they are swept away to the lab to be united with the sperm that has now been prepared for insemination or intra-cytoplasmic sperm injection (ICSI). With insemination, sperm will be placed in a petri dish and left to their own devices to find and fertilize the egg. With ICSI the embryologist will pick one healthy looking sperm from the sample and inject it directly into the egg.
Image by Wellcome Images via Flickr
This process begins four to six hours after egg retrieval. The would-be embryos are placed in an incubator and assessed 16 hours later to determine if fertilization was successful. Successful fertilization is indicated by the presence of two pronuclei. Fertilized eggs will be placed in culture media that mimics the fluid found in the fallopian tubes, which is where your embryo would be at this stage if fertilized in a natural cycle.
You will know how many eggs you have right after retrieval, but you have to wait a whole day to find out how many of those eggs fertilized. A whole day!
Two days after fertilization the embryos will be briefly assessed to ensure they are dividing properly. If there are a number of embryos dividing properly, the embryologist may decide to allow the embryos to continue to grow to the blastocyst stage on day five or six. If only a few embryos are dividing properly, the embryologist may suggest a transfer on day three after retrieval. You will typically receive a report on day three even if you are transferring on day five.
Our Day Two Embryos From Spork’s Frozen Cycle
There is an ongoing debate about whether it is best to transfer embryos on day three or day five. Many doctors believe that embryos that don’t make it to blastocyst stage on day five or six in the lab would be unlikely to do so if transferred to the natural environment earlier. By allowing weak embryos to die off in the lab you increase the chances of the remaining embryos implanting. The opposing view argues that it is impossible to replicate the womb perfectly and that embryos are better off when they return to the natural environment as soon as viability can be determined.
If your embryo is transferred on Day 5 or 6, it will be placed in new culture media that replicates the uterus, which would be its environment three days past ovulation in a natural cycle. A blastocyst will contain 80 to 100 cells and has a clear inner cell mass (ICM) and trophectoderm visible. The ICM will eventually become the baby and the trophectoderm will become the placenta.
Day Five Blastocyst Image by Prescott Pym via Flickr
Stages of Embryo Development
Day 0 – Retrieval. Insemination or ICSI occurs 4 to 6 hours after retrieval.
Day 1- Embryo assessed for fertilization. Must have 2 pronuclei present.
Day 2- Cleavage stage. Cell division occurs and embryo has 2 to 4 cells.
Day 3- Embryo has 6 to 8 cells. Embryo could be either biopsied for testing or transferred on this day.
Day 4- Morula stage. Embryo compacts into a small ball of 16 or so cells.
Day 5- Blastocyst stage. Embryo expands and a clear ICM and trophectoderm are visible.
Day 6- Last day an embryo can survive in an incubator. It must be transferred or frozen at this stage.
Step 7- Mama I’m Coming Home
It’s time! Whether you transfer on day three or day five, the time has finally arrived to welcome your embryo or embryos back home where they belong. The transfer is an important part of the IVF process even though it is usually very simple and totally painless. In fact, the procedure typically only takes only about 5 minutes.
Because of this I found it to be a lot like my wedding day. We worked so hard and put so much effort into something that flashed by in the blink of an eye. Still, just like a wedding, it is a very special time which is sure to leave you and your partner beaming and exhausted.
You may make the final decision on how many embryos to transfer and what to do with the remaining embryos immediately prior to transfer. This way you have the most recent embryo development information available to aid in this difficult choice. Your doctor will give you pros and cons but the final decision is up to you. Any remaining embryos can be frozen (cryopreservation) for future transfer.
While the decision on how many to transfer is up to you, there are limits to what some countries and doctors will allow. No sensible doctor would have let Octomom to do what she did. We in the infertility community genuinely despise her doctor for the bad rap he gave IVF and all the explaining we have to do as a result of his ineptitude.
Image by Alanak via Flickr
Once you have determined how many to transfer, the embryologist will load the embryos into a special catheter designed for transfer. The doctor will slowly inject the embryos into your uterus using guided ultrasound. Unlike embryo retrieval and follicle monitoring, this ultrasound will be an abdominal scan in order to avoid potential uterine contractions and to allow a clear path to the sweet spot. This means you will need to have a full bladder for the procedure to allow the doctor to have a clear view of your uterus.
Image by Carbon Arc via Flickr
The full bladder is the bane of the IVF patient’s existence. It is very difficult to know when and how much to drink in order to get the bladder full enough for a successful transfer but not so full that you wish for death in the hour you lie immobile and holding it after transfer. Follow the advice of you doctor, but I have been told 8 ounces 45 minutes to an hour prior to the procedure is more than enough.
The “sweet spot” from our last transfer
Once your RE locates the “sweet spot” he will release the embryos along with a puff of air. The catheter will be given to the embryologist to look under the microscope and ensure that the embryos cleared and ended up in the uterus. You will remain immobile and reclined for 15 minutes to an hour. Some clinics prescribe bed rest for a day or two after transfer while others do not. Recent studies suggest that bed rest can actually decrease success rates, but the jury is still very much out on this one. I personally like the day of bed rest so I don’t have to return immediately to the real world and can luxuriate in my potentially pregnant state. Plus my husband has to take care of me. That’s why I think clinics will be slow to remove the requirement if it is indeed proven to be unnecessary.
The next step is the blood pregnancy test, also called a “beta” which measures the level of HCG in the blood. HCG is produced by the embryo after it implants into the uterus beginning as early as 7 days after retrieval. Timing of the test varies by clinic, but typically falls 14 days after retrieval.
HCG is the same hormone that is usually injected to trigger ovulation. For this reason, many women will start taking home pregnancy tests after trigger to see when the HCG tests “out” of their system. After the HCG is tested out, any positive pregnancy test is likely to be a real pregnancy and not just remaining HCG from trigger. HCG is generally gone after 10 days but I personally don’t mess with taking home pregnancy tests during fresh cycles. There is too much potential for the HCG trigger to mess with my already overly worried mind.
If you are pregnant, a second pregnancy test will be ordered to ensure that HCG levels are rising normally. You will also continue to be monitored by your clinic through blood work and ultrasounds until week 10 or 12 of your pregnancy before you “graduate” to your regular OB or other specialist.
If you are not pregnant, you will schedule a consult with your doctor to review the cycle and discuss next steps. It’s a good idea to bring a list of questions to this appointment to help stay on task with this discussion. If you aren’t pregnant, its important to note that many people do not get knocked up in their first IVF. In the same way that fertile couples don’t always get pregnant the first month they try to conceive, IVF can take some time.
This is a hard pill to swallow given the expense and emotional strain involved. The general rule of thumb is that the majority of couples will get pregnant by the time they complete 3 full IVF cycles. After the third cycle the success rates plateau and it may be time to consider alternatives like donor eggs, donor sperm, gestational carriers, adoption, and living childless. However this is a generalization and your treatment plan and next steps should be determined by you and your spouse with the help of a trustworthy Reproductive Endocrinologist.
Whatever your outcome, I hope this post will help you understand a little more along the way. If you want to have a child you will have one, although it may play out differently than you dreamed.
Whatever you do, don’t give up on your dream until you are sure its the right time for you.
Best of luck to you. Take care of yourself and your relationships on this journey.
We had our Homecoming at New/Old clinic yesterday. Bill and I are both thrilled with the plan we have developed and also the stark difference in bedside manner and genuine caring we received from every individual we interacted with, especially our doctor.
I must confess that it was only six short months ago that I was angry with this clinic. I never stopped loving our doctor or nurses, but our last cycle was tough. We had a difficult transfer, lost 4 embryos total in the freeze/thaw process, and ultimately had a miscarriage. It was time for us to try something different and we did, even though I had a nagging feeling that I shouldn’t leave a team of nurses and doctors who understood me, my body and my history so well.
Over the years I have gone back and forth on the importance of beside manner. Does it matter? Do I care whether my doctor is nice to me, or for that matter even takes a moment to speak to me, as long as he gets the job done?
As it turns out, yes. It does matter to me. I want a doctor who listens to me, who has obvious passion for our joint objective, and who appreciates the power he has to eliminate stress in one aspect of this intense process.
I have that in New/Old clinic and it was clear yesterday.
First, rather than spending only 4 minutes with my doctor, we spent more like 40. Surprisingly, he put his ego completely aside and reviewed with me every aspect of my cycle with Celebrity Miracle Clinic. We discussed what we liked and didn’t like and adjusted our plan accordingly. There were a few things he said “no” to putting in the plan, but when he did he justified it with studies and science.
One example of this is intramuscular injectable progesterone. He agreed to let me do less painful suppositories, but only after I am pregnant. Studies show an ever so slight but still meaningful increase in pregnancy rates with injectable progesterone because suppositories can cause cramping and the implantation threatening uterine contractions that come a long with it.
We were most pleased with how much we accomplished yesterday and how flexible the clinic was in making it happen. Our appointment was only for a consultation, but when I told our doctor that I had a cyst since February that hadn’t budged despite being suppressed the whole time, he immediately squeezed us in for an ultrasound. When we saw that the little booger was too big to ignore, we weighed the options and decided to drain it in a painful but quick procedure. They made this happen even though is wasn’t “in the schedule” and it was late enough in the day we would likely be keeping the entire office there well past closing time.
To prepare me I was given a high powered antibiotic and 800 mg of ibuprofen. Because both could upset my stomach I was given crackers and juice. When I told the nurse I was gluten-free, she was clearly ready to check with the entire staff to see if there was anything they had in their personal stashes that I could eat. I told her that I thought it was a good excuse to break the diet and that it had been months since I had Cheez-its so not to worry.
When she left the room my husband turned to me and said “She is going to go ask everyone here if they have anything you can eat. The other clinic would have sent us to their kiosk down the corridor from their big beautiful waterfall and wouldn’t have given a damn.”
While I am not sure that is true, the point is we feel like this clinic really cares about us. Our doctor cracks us up because after decades in the business he still is obviously super geeked about advances in ART technologies. He doesn’t talk down to us and also recognizes the value of our opinion. But most of all, we are so impressed that the clinic recognized how far away we were from home and did what was necessary to remove the cyst rather than having us come back, or worse, waiting another month or two to see if the cyst went away on its own.
That just couldn’t have happened at Celebrity Miracle Clinic because access to the doctor is too limited and the clinic is too big to be that nimble.
So as you can tell we are pleased with our decision. While it may have taken more green to prove it, the grass is not always greener on the other side. And even more importantly, we are excited about our plan and even a bit surprised by some of the changes we made. Here it is in short form. As we progress through it I will pick it apart and explain the “why” behind some of what we are doing in more detail.
1) Stop birth control on April 16th and start maximum dosage of stimulation meds on April 18th. I love that we aren’t wasting any time and that we are beginning with the highest dosage to enlist as many of my resting follicles as possible. I will take 150iu of Menopur in the morning and 300iu of Gonal-F at night to stimulate growth of the egg yielding follicles in my ovaries.
2) Begin taking Omnitrope, a name brand of growth hormone, when I begin stimulation medications. I will inject 24iu a day during the entire time I am stimming. Studies show that this can improve egg quality in older women. It is theorized that because naturally produced growth hormone decreases as you age its decline may cause quality issues. Sample sizes are small for these studies but results are promising.
3) Use Cytotec to soften the cervix due to my difficult anatomy 7-10 days prior to transfer. The doctor also scheduled the transfer at a time that he was sure to be the one to do it since he knows our history with difficult transfer. We will also check my bladder level prior to going back for the procedure since it has been a problem for us in the past.
4) Inject HCG into the uterus the day prior to transfer to increase implantation rate. Studies have shown that growth factor injected into the uterus prior to transfer increases implantation rates.
5) Use time lapse photography to take snapshots every 8 seconds of the first two days the embryos are developing to rule out embryos that are not developing properly and are likely aneuploid (abnormal number of chromosomes). While this is not as accurate as genetic testing, it works to accomplish the same outcome while not damaging the embryos.
6) Assess on day two of embryo growth whether we freeze all the embryos or proceed with a fresh transfer on day three. This was a surprise. I thought we had ruled out a fresh transfer but both my doctor and my husband want to proceed with a fresh transfer if we have a number of good embryos. We will prepare my body for a fresh transfer and make a game time decision. I am as nervous about this as I am excited because it means I may be pregnant the first part of May, the same month I conceived Spork.
I feel like with this plan we are doing as much as we can to give this cycle the best chance of success possible.
We spent the entire afternoon building this plan and removing the cyst which could have been a taxing and exhausting experience. But it wasn’t. If anything it was invigorating. We accomplished so much in one afternoon, removing all obstacles and setting up our plan of attack. It wasn’t taxing at all because we weren’t in some sterile, cold, and beautiful mecca of fertility where our doctor was kept safely behind a curtain.
I spent the majority of the day worried that my treasured iTunes library with all its organized playlists had disappeared forever. I spent two hours with Apple support and an equal amount of time beforehand in chat rooms and reading troubleshooting links trying to avoid Apple support.
Of course I backup my Mac regularly like any responsible person who stores thousands of songs and family photos on her computer should so it shouldn’t have been a problem, right?
Yeah right.
I diligently backup like every 8 months or so.
I wasted the evening away desperately searching for a way to not have to go back to July of 2013 to replace the playlists. Early on in the process I was able to recover the music, but not the playlists. There was a point where I nearly gave up and accepted that it was enough to have all my music even if it wasn’t organized neatly in a slew of lists that together represent a chronological and musical expression of my entire being since I became an Apple user.
These playlists mark so many phases of my life. As a runner, I have playlists for certain distances that I run. For a short time today, the playlist that kept me company for nearly (but not quite!) four hours during my first marathon was lost. And there was so much more, like the first lullaby list I made Spork and countless playlists I have created as gifts for special people at special times. And let’s not forget my myriad fertility playlists with meditations and music put together in collections designed for specific stages of the IVF process.
All were gone for this short but panicked period of time.
I have mentioned before that I am Type A. This is why I have playlists that are the perfect length with just the right BPM to cover 5, 7, or 10 mile training runs. This is why I have multiple fertility playlists. This is why I spent the better part of the evening turning over every cyber rock I could find to determine how to get these playlists restored without losing a single song. It wasn’t easy, but I did it. I won.
I usually do.
In the fertility world, this type of behavior makes me a cliche. I am about to embark on my fifth IVF because I waited too damn long to start trying to get pregnant. I had a world to conquer, a career to develop, and a Master’s degree to complete before I could even fathom making babies. When I finally got serious at 34, we discovered that baby making was going to require more effort than all of these things combined.
So its no surprise that like a lot of women I try to exert as much control over the process as humanly possible. I do this despite knowing that IVF is a process that you simply cannot control. I have written before on the importance of acceptance and I believe fully in the mental benefit of being at peace with the fact that there is very little you can do to control or change infertility.
I fall short, however of relinquishing all control. There are certain things you can influence in IVF and as with other things in life I choose to live by the rules of the Serenity Prayer, letting go of those things I can’t control and controlling what I can.
There is so much with infertility that we have no ability to impact. Ultimately I cannot control whether we will have another baby or not. But I think its necessary to recognize that you can influence certain aspects and do your best in the process. There are things you can control. Many things.
I can make sure I take my shots on time and schedule my meds to arrive when I need them. I can control how I manage stress. I can control my weight. I can control my nutrition and exercise regimen. I can control my quality of care by being an educated patient who asks questions and advocates for myself.
You get the idea.
This is why we are taking an ungodly number of supplements. Its one tiny little thing that we can do to improve our odds of success.
Each and every single one has some added benefit that in one study or another led to increased success rates. Every item on the list has been vetted by one of the best clinics in the country and they believe it could have a positive impact.
So why not take them?
I do, however, think its a good idea to keep our ability to directly influence the outcome in perspective. My eggs have been with me since birth and we are having trouble because they are getting old and sticky, no longer dividing cleanly and quickly. All the Coq10 in the world is not going to reverse the impacts of aging.
However we have noticed a difference in our lab tests and our actual cycles since starting this regimen last year. My resting follicle count increased and our embryo production improved by 26% (22 resting follicles produced an additional three embryos). Bill’s count and motility were always good, but his morphology improved from the very low end of the range to the high end of the normal range in the last two specimens since starting the supplements.
So yes, the crazy number of supplements are probably an exercise in exerting control over infertility. But I don’t think that’s bad nor do I feel its futile. If it creates that one super healthy sperm that unites with that one magical and nutritionally nurtured egg to make a perfect little baby it will have been worth it.
I can’t change who I am any more than I can change the fact that we are infertile. It’s in my nature to try to control and influence. My DNA doesn’t allow me to give up without a fight. But I have at least learned to not allow the ability to control give me the false sense of responsibility when a cycle fails. That is the risk you run with trying to control infertility. If you accept that you can make a difference, then it is all too easy to make the mental leap that you are to blame when things don’t go well.
You cannot blame yourself when things go badly. What you did still may have had a positive impact, it doesn’t mean you did something wrong any more than it means you should stop trying to make a difference. Just pick yourself up, dust yourself off, pop a few more supplements, be compassionate with yourself and proceed to Plan B.
It has been a busy, hectic, and emotional week. In fact we almost haven’t had time to process what happened last Friday.
Almost.
While I felt guilty in the moment, looking back I do not regret caving in the 11th hour and taking the home pregnancy test. Testing before the official test allowed us to leave early for our weekend of water sliding and cleared Friday night for much needed time to discuss the sad news and what would come next.
Our discussion that night was one of the most challenging in our marriage. Bill and I process bad news in different ways which often leads to disagreements during times when we should be most supportive of each other, like the night of a failed pregnancy test. Especially this failed pregnancy test.
After eight procedures, twenty embryos, one miscarriage, and putting all our hopes and money into the Celebrity Miracle Clinic for one full cycle, we were both reeling and not at all in a position to give to the other what was needed that night. The weight of a disappointment of that magnitude could crush even the most perfect of couples.
Because so much of the IVF process centers on me, it is easy for me to forget that we are both invested in this. We are both elated when we are at a peak and devastated when we are in a valley. I have often made the mistake of expecting Bill to be there to take care of me, to put me back together when I am falling apart, only to realize that he may not be whole himself. This was the case Friday night.
Adding fuel to the fire, we were not at all aligned with what we wanted to do next. I decided long ago we would go back to Celebrity Miracle Clinic for one more attempt at creating a baby with my own eggs. Who cares that we didn’t like our experience there? I reviewed statistics for the best clinics in the country and determined that Celebrity Miracle Clinic was the place to be for an old lady with egg quality issues who was serious about getting knocked up.
Bill, on the other hand, has a deep seeded dislike of Celebrity Miracle Clinic and suggested in a less than subtle way that we consider alternatives.
Cue massive, explosive argument.
Throwing a wrench into the recovery plans of a hormonal Type A infertile woman is bound to cause a wee bit of a problem. It was a long night. Hurtful things were said. The evening culminated in our holding each other at 2 AM seriously discussing whether or not we could go through IVF again at all.
In the physical world, some explosions are devastatingly destructive. Others are critical steps toward building something new and breathtaking, like an expansive tunnel to the other side of an enormous mountain. I feel that Friday night was creative destruction, the clearing of one set of ideas and mental debris that allowed us to find a new path through this huge obstacle in front of us.
The truth is I don’t care for Celebrity Miracle Clinic either. Take for example what happened Saturday. I went for my blood work at 6AM mountain time. At 12:41 PM a nurse from the clinic called me to see if I had done my blood work. I told her that I had. She was then supposed to call the lab and call me right back to give us the results. Five hours later, there was still no call and no results. I eventually called the after hours answering service and had to demand to speak to the on call nurse because I was told “lab results are only discussed during normal business hours.” After five phone calls I finally received a call back with the results of my long awaited pregnancy test.
This type of thing happens all the time at Celebrity Miracle Clinic, but I explain it away and suppress my feelings about it because they supposedly have the best lab and results in the country.
Bill’s suggestion that we consider going back to our old clinic, the one that gave us Spork, made me angry at first. But the more I thought about it, the more it made sense to me.
We initially went to Celebrity Miracle Clinic because we didn’t know if we were still making chromosomally normal embryos. While our old clinic can do genetic testing, they do it at an early embryonic stage that can damage the embryo to the degree that makes it less likely to survive and implant.
Celebrity Miracle Clinic uses technology that allows the embryo to be biopsied at a later stage and therefore does less damage to the embryo, using only a small number of cells from the part of the embryo that will become the placenta.
I debriefed with my Celebrity Miracle Doctor on Monday. He said that we had three genetically normal embryos that were of good quality and we were just “unlucky” this time.
Hmmm… maybe. Maybe it’s a little more than just bad luck.
In our cycle at Celebrity Miracle Clinic we had 5 embryos make it to the blastocyst stage. Of those five, the initial genetic test results came back with two embryos as genetically normal (euploid), one abnormal (aneuploid). The remaining two embryos had to be retested because the tests were inconclusive.
What? Retested? What does that mean?
That means Celebrity Miracle Clinic achieved a 40% failure rate on their amazing state-of-the-art testing and we had to do it again. After retesting, one embryo came back abnormal and the other embryo was Blob. In order to be retested he had to be warmed and biopsied a second time, removing even more cells from his 100 or so to support the test.
When Blob was frozen the first time he was a 5BA blastocyst which meant he was still in his shell. During the second biopsy he completely reanimated, expanded, and even shed his outer shell. Then he was flash frozen again.
After that he was never the same.
Embryos are supposed to fully expand after being warmed. In fact, re-expansion is the most important indicator for a successful implantation. Blob barely had a chance once he was warmed again and only slightly expanded.
What Blob looked like at transfer
What Blob should have looked like at transfer
Had the test worked the first time, or had Blob not been tested at all, he could be happily growing inside me. There is no way to know, but the testing could have been too much for him. It could have been too much for the other two normal embryos that didn’t implant in January as well.
My new/old clinic transfers embryos at an earlier stage, generally untested but also undamaged. Now that we know more than 25% of our embryos are likely to be chomosomally normal, we can go back to the new/old clinic and continue with some confidence that it will likely just be a matter of time and patience before one of those embryos sticks and becomes Spork’s sibling.
While we do run an increased risk of miscarrying an abnormal embryo that wouldn’t have been transferred at Celebrity Miracle Clinic, as well as an increased risk for Down’s Syndrome or other chromosomal issues, these risks aren’t higher than any other 38 year old who gets pregnant and are still relatively low. The trade off is that we put the embryos back to their natural environment without damage sooner, which bodes well for delicate embryos.
Armed with this knowledge, today we said goodbye to Celebrity Miracle Clinic. I sent the official form from new/old clinic requesting all my medical records. I called my nurse to tell her voice to voice. It felt a little like an overdue break-up, like severing a slightly dysfunctional but at one time mutually beneficial relationship that is no longer beneficial.
We said goodbye to more than just a clinic with that call today. At our first consultation with them back in July we were so filled with the hope we would wind up on the right side of their jaw-dropping statistics. We were mesmerized by their program and amazing facility. Today we are no longer awe-struck. We said goodbye to that child like wonder and the certainty that Celebrity Miracle Clinic would swoop in and fix what was wrong.
We also said goodbye to Blob today. Even though I knew at transfer he had a slim chance, I fully believed he would make it. The start of my period today underscored the fact that he did not, something I have known since Friday but becomes so real when this time comes, the time when a cycle officially comes to an end and a new one begins.
While a little saddened, we are also turning a page. I received a call with the plan from the new/old clinic today thus taking our first steps through the tunnel we blasted into our own personal mountain. While the pain of goodbye is still fresh if I dwell on it like the pain of a fresh break up, there is nothing like the promise of a new relationship to help the memory fade.
It’s already time to look forward.
And so it is with infertility as it is with so many things in life.
Every year at this time I ponder the meaning of life and face my own mortality. 19 years ago today this Daddy’s girl lost her real life super hero to an 8 month battle with cancer. I was four days before my 19th birthday and he was only 41. Tragically, I am the oldest of four and my youngest sister was 11 at the time.
This year marks a sad turning point, I am officially crossing the threshold of time where I will now have spent more time without my Dad than with my Dad.
Everyone expects to someday lose their parents, at least parents pray that is how things go. Its how things should go. But when you lose a parent too soon, when that parent dies young, it forever affects your view on the world and your own mortality. Since I hit my thirties, I have been counting down to 41. The number looms around my subconscious daring me to surpass it and taunting me with dark possibility.
Last year, I decided to start making a video for Spork every year on this day. I sing her favorite songs, talk to her about how much I love her, and detail her milestones. I do this so if something happens to me, if I leave her too soon, she has 10 minutes of Mommy tailor made for her age and needs right now.
Between all of this and the imminent birthday, I cannot help but to contemplate the meaning of life and my own mortality. Of course, fertility is a factor. I keep thinking that if we get pregnant this cycle and I only make it to 41, I will leave Bill with a 5 year old and a 3 year old. I wonder if its irresponsible of me to even try. I worry what will happen to my little girl if she goes through her formative years without her Mommy.
Two nights ago, it all came crashing down on me. Lying in bed with Bill asleep beside me I began to question my faith and whether there really was an afterlife. My thoughts on the topic are for a different blog, but in the midst of what was threatening to turn into a panic attack I woke Bill up to discuss it.
Me: “Bill.”
Bill: No response.
Me: “Bill. Are you awake?”
Bill: Some rustling and grumbling.
Me: A little louder and acting surprised “Bill, you are still awake too?”
Bill: “Uh…Yeah.”
Me: “Oh good. I am freaking out a little bit. Do you ever start thinking about the meaning of life and freak out?”
Bill: “No”
Me: “Do you ever start thinking about what happens to us after we die and panic or get really scared?”
Bill: “No”
Me: “Oh. Okay. Because I am really freaking out.”
Bill: “Don’t freak out.”
I could tell from the grumbling and heavy breathing that followed that he was not awake enough to get me through my mini crisis and I was on my own. I did some deep breathing, a little meditation and eventually fell asleep.
And then I had the most amazing dream.
I won’t go into the somewhat weird and unimportant details, but I dreamed of my Dad. We talked. I don’t remember all the fine points of what we discussed or for how long but it seemed like it was all night. I do remember the sound of his voice. It has been so long since I heard it but it was unmistakably him. At one point I reached up and touched his face and I could actually feel the texture and temperature of his skin. It was so vivid and real. He had unique skin that was tough but soft at the same time, especially after shaving. I rarely dream of my Dad and have never had a dream like this. I didn’t want to wake up, and when I did I was exhausted even though I slept through the night.
Despite all my fertility superstitions, I am generally grounded in reality. I realize there is a limit to how much we understand about the universe but my open-mindedness stops short of believing that dead parents visit their kids in dreams. While I don’t remember the various things we talked about, I do remember the general feeling of the conversation was comforting. It felt like he was trying to put me at ease. He was letting me know he was okay and that I was going to be okay. Maybe this was a sign? Maybe he was visiting me from the great beyond to bring me peace?
And then he said something I do remember very well which totally shattered my illusions about it really being my Dad:
“I really miss fried okra. I wish I could have some fried okra. With bacon.”
Dad did like fried okra. And he liked bacon too. You can’t tell it from the photo in his twenties, but he rarely met a food he didn’t like which is at least part of the reason he is not here today. He could have used more exercise, a healthier diet, and a job that didn’t surround him with second hand smoke. But however much he loved fried food, I have to believe he would not travel through time and space and pierce the vail between two worlds to tell me he had a craving.
I know that what I experienced was probably just my slumbering brain working through its issues. I was unconsciously reconciling the pressure of getting closer to 41 and lamenting the loss of my father and my youthful eggs.
Still, I woke up at peace. Touching his face and hearing his voice gave me the feeling he was still with me, even if he wasn’t visiting me in my dreams. I knew with unshakeable certainty that just like I am okay, my little girl and her (God willing) sibling will be okay. I knew right away that as a parent I needed to accept that I can’t control what happens to them or to me in this life. I can give them life, give them my best, and pray.
I don’t know the meaning of life, but I am pretty sure we should soak it all in and savor every sweet moment. Kind of like the way Dad would have savored fried okra and bacon.
And just as it is with my Dad, I would rather have my family and this life for a short time than not at all. However I have a feeling that someday my kids will be watching decades worth of annual videos of their happy, old, crazy Mom.
I have been thinking a lot lately about whether or not to share the names of my clinics and have decided against it. However where we are currently going will become increasingly obvious to some of you as we tell our stories. It will be very apparent to you if are at all experienced with IVF and have done any research on the best clinics. It will also be clear to you if you watch a certain reality show on E!
If you do watch that show you have met my doctor, a couple of the nurses, and have seen the building that we affectionately call “The Mecca of Fertility.”
Hint. Hint.
Google it if you want. If you look hard enough you will find it. But I didn’t tell you. Not officially. Being new to this blogging stuff I am not sure that refraining from spilling the beans protects me from legal action but I feel better being a little discrete. If I become pregnant and famous I am sure the clinic would love for me to plaster its name everywhere, not that it needs more publicity. But until that time and not knowing the outcome I think its best if I take the safe route. Especially given the story I am about to tell you.
So yes, our clinic is world famous. The founder is our doctor and he literally wrote the book on assisted reproduction (another reason to fall madly in love with him as discussed in a previous blog). Couples from all over the world come to our clinic in the hopes that their dreams will be realized. It is the clinic of choice for those that can afford to travel and pay for the best. It is where celebrities go to get help with baby making when they hit the conception wall.
Yes, our clinic is the clinic of the stars and it has the price tag to match. And it is that price tag that turned the Winslow’s into thieves one day in August of 2013.
Most of the clinic’s clients are like us. They have been through multiple cycles at clinics closer to home and have switched hoping to break a losing streak. As result, the clinic is dealing with patients that have already had extensive fertility testing. But that doesn’t matter, every patient has to go back through all the testing again. The clinic feels they are the best, have the best labs, the best doctors, and their reputation is not going on the line based on shoddy work done by a previous clinic.
So no matter what your history the clinic does all the diagnostic testing from scratch in a session they call a “One Day Work Up.” In our case it meant a flight out to see them to do a myriad of tests and an orientation session. This day was spent waiting to meet with billing, waiting to meet with our assigned nurse, waiting to see the doctor for a variety of tests, waiting to give blood and other samples. It was a day of waiting, waiting, waiting. For each appointment we had to check in at one of three reception areas.
Each of these reception areas had an ever so tempting cup of brand new pens with the clinic’s name and logo on it. Nice pens. The good stuff. The kind you would expect from a celebrity’s clinic.
Bored from all the waiting, we decided to make a game of stealing the pens. Our goal was to take as many of those pens home as humanly possible thinking that it would help justify the expensive price tag of the trip. Each time we would check in for an appointment we would find a reason to have to write something down, use a new pen, and take it back to the waiting area with us to stash in my purse. We laughed so hard each time we would successfully “steal” a pen that was clearly there for us to take anyway.
We passed time dividing the number of pens into our estimate of what one full cycle at the clinic would cost us. This gave us an estimated value of each pen. The more we would take, the more the value of each pen would decline. When it was all said and done, over the course of the day we took 6 beautiful pens. Since that time we have added two more pens from subsequent visits.
Based on our number of pens and what we have spent so far each pen has a value that is still more than some people’s used cars. As a result, I use these pens all the time. I feel like I have to get my money’s worth.
I also have a sense of pride and a flittering of hope every time I touch one. As much as I like to joke about stealing the pens and the price of the clinic, whatever we end up spending is worth every hard earned dollar . We know that before we give up on the dream of having a sibling for Spork we will have gone to the best and given it our all.
We are uniquely blessed to have the ability to be able to do this. We would never have been able to afford it even two years ago. But we have had a lucky couple of years that have made it possible to shell out the big bucks for the big guns. It means postponing a new addition to the house and really tightening the belt, but I can’t think of another thing I would rather have more than this.
The results of our One Day Work Up didn’t tell us anything new. We looked good on paper. My hormone levels, resting follicle count, and other key factors all were perfect. Bill’s little swimmers were in Michael Phelps like condition. The doctor said he didn’t usually see patients like us. His cases are usually more difficult.
Since then we learned our embryonic cells divide a little more slowly than they should and the optimism has faded ever so slightly. Its a sign that my advanced maternal age could be the reason we are having so much trouble this time. But we are still making genetically viable embryos and that is why we chose this clinic. They were the best to help us answer whether there was still hope for us, and there is.
Whatever the outcome is for our family, Bill and I will be able to rest easy knowing that we have given it our best shot. But if the worst happens, if it doesn’t work, at least we’ll have the pens. All eight pens…and counting.
Laughter Through Tears 