difficult embryo transfer | Laughter Through Tears

Ultrasound Number 3- Day 9 of Stimulation

Over many years and cycles I have developed a series of informal rules for IVF in order to protect me from me. These are simply things that I do or do not do in order to remain emotionally sound and balanced as I navigate this challenging process. Last night I not only broke one of my rules, I completely anhialated it. And it was one of the most sacred rules I attempt to follow.

I cruised into Grand Rapids early enough to find a delicious organic and gluten-free friendly restaurant and had an amazing meal. After my sweet potato and quinoa burger I was anxious to get back to the hotel and take advantage of some “Mommy time.” I had big plans to blog my little heart out.

But I didn’t write a word. Not one single word.

Why?

As soon as I opened my Macbook I lost all self control and proceeded to spend the entire evening with my old friend Dr. Google. I was frantically seeking reassurance the cramping and bleeding from Thursday night wasn’t going to delay our transfer.

As is always the case, all I found was more reason to worry. Since it was late Friday night and I was all alone, I had no doctor to calm my fears. There was no husband to tell me to shut the computer, calm down, and go to bed. I was up past midnight, which is kind of tough for an old lady with a 6:30 AM injection and a 7:30 AM ultrasound.

And to think when I checked into the hotel I was worried the busloads of teenage girls in town for a big volleyball tournament would keep me up late.

I bet I outlasted them all.

No matter what the situation, spending too much time with Dr. Google is never a good thing. I am the first underscore the importance of educating yourself and being your own advocate in all things fertility related. It is critical to research and question your clinic’s plans, but only within reason. There is a distinct difference in learning about a process and relentlessly searching the internet in an attempt to find answers.

What I found last night was unsettling. There was a dearth of information of using cytotec prior to embryo transfer, but the data available about cervical dilation prior to embryo transfer made it very clear that the procedure should occur a month to three months in advance of the procedure. Pregnancy outcomes when a cervix is dilated too close to transfer drop to almost nil. One study had a 0% pregnancy rate for cervical dilation at embryo retrieval. Another study had a 2.5% pregnancy rate for cervical dilation two days prior to transfer.

Our transfer should happen sometime next week, a measly 5 to 7 days from taking the cytotec.

Cue major freak out and sleepless night.

Needless to say I was anxious to see the doctor today. In fact I practically accosted him when he entered the exam room. I don’t think I even said hello prior to telling him about the bleeding and hysterically citing all the studies that stole my shut eye.

Turns out, the doctor knew all about the studies. In fact he knew a lot about them that I didn’t know, like the essential fact that the cervical dilation referenced in the studies is a stretching of the cervix that happens under anesthesia and creates trauma that needs to heal prior to a successful transfer. The cytotec that we used has a very short half life and did not actually dilate my cervix, it only softened it.

Most importantly, the ultrasound showed a uterus with the correct triple pattern measuring at 10mm. This is absolutely perfect for this stage of IVF. We could even see on the ultrasound that the bleeding I experienced had come from the cervix and that we could expect a little more over the next few days as it clears up.

Everything was perfectly normal and exactly as it should be.

I was worrying over nothing, as I seem to do when my estrogen begins to approach 2000. I always get a little bit crazy at this stage of stimulation. While being so close to retrieval is exciting, its a lot to manage when your body is processing all the hormones as well as physical distortion and discomfort from enlarged ovaries full of follicles.

Speaking of follicles, would you believe they are the exact same size as two days ago? The meds are still working, its just that my clinic measures differently than the local hospital that monitors me closer to home. According to the doctor its not uncommon to have a 2mm difference with a different machine and user which is why they have me travel the three plus hours for monitoring as we get close to time for retrieval. My largest follicle is still 17.5mm which means we have a little more time than I thought.

I have another ultrasound at the clinic Monday morning to confirm, but it looks like we are back to the original plan of triggering Monday night, retrieving the eggs on Wednesday, and transferring on Friday.

So today was another ~~inspiring~~ distress eliminating appointment, especially since the left ovary seems to be producing a few more follicles large enough to give us eggs. I am not sure how many good follicles we have though, because in all the excitement and desire to resolve my cervical dilation fears I completely forgot to ask about the number of follicles and my estradiol level.

But its okay. I don’t need to know all the details. Really, I don’t. Last night was a reminder that sometimes its good to put a little faith in your doctor and take a break from questions and data. Besides, after tonight I am only one lonely night in a hotel room away from getting a final pre-retrieval count Monday morning.

Between now and then, I am saying farewell to Dr. Google.

Ouch…

Just when things when things were cruising along and we were feeling super confident about this cycle… WHAM. A problem comes and hits us right between the eyes. This is not uncommon with IVF. For me at least it always seems I have one or two roadblocks along the way to transfer.

Nobody said it would be easy.

Last night through a new curveball at us, one that I am hoping doesn’t cancel our transfer. Our eggs should be fine, but I am concerned we may have to freeze all the embryos and wait until next month to bring them back home where they belong. I hope I am getting way ahead of myself and that my early morning scan tomorrow proves otherwise.

What happened?

For those of you keeping close tabs on our journey, you know that I often have difficult embryo transfers. The transfer is the most delicate part of the process, when our precious would-be babies are most at risk. Having a smooth transfer is a key indicator of success and it is the “art” behind the science of what the Reproductive Endocrinologist does. I have a tough cervix due to past surgeries and my uterus is also extremely retroverted. If the follicular ultrasound is like the Triple Lindy for sonographers, my transfer is like an Inward 4 1/2 somersault from the 10 meter platform for the RE (this is the most difficult olympic dive according to Google, for those of you who are unfamiliar).

Image by Victor Valore via Flickr

To help navigate my disagreeable anatomy, I take cytotec prior to transfer to help soften the cervix and make everything a little more hospitable. This allows the catheter which will transport the embryos to gain easier access to the sweet spot. Its rarely done, but my situation is pretty rare.

We used cytotec for the first time at Celebrity Miracle Clinic and it did indeed help smooth the process. So when I returned to Home Clinic we added it to the plan. However my RE wanted to move the cytotec closer to transfer to obtain the max benefit from the softening. At Celebrity Miracle Clinic I took the cytotec almost a month prior to transfer, and not while taking stimulation medications. This meant that there was very little going on in my abdomen at the time and all I experienced was some persistent and moderate cramping.

Well guess what? When taken close to transfer with a lush lining and ovaries the size of oranges, it really flipping hurts and also causes bleeding. And why wouldn’t it? That is what the Cytotec is designed to do.The drug is used to induce labor and miscarriage. With additional pressure in the abdomen from oversized ovaries and a perfect lining it only makes sense that there would be some pain and even bleeding.

I have never experienced full on labor, Spork was a c-section baby taken at 37 weeks due to a compromised placenta, but I feel like I got a glimpse of it last night. It was so bad that we called to neighbors, my Inlaws, at 1 AM to see if they had Tylenol. Acetaminophen is the only pain medication approved during IVF and we had picked a heck of a time to run out. When Bill’s parents came up empty, he had to leave the house to track some down. There was no way I was sleeping without some help with the intense pain.

I am still crampy today but much better, but there is still some bleeding. The question is, is the bleeding from my lining? Will my lining still be thick enough and retain the right patterns for transfer? We have to wait and see for the ultrasound tomorrow.

I am so hopeful the little bit of bleeding is an irritated cervix and the lining is still intact.

Fingers crossed that we are still a go for transfer.

I simply cannot wait until tomorrow.

Who Says You Can’t Come Home Again?

Image:David Simmer II via Flickr

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.

We were home.

Chicken And Rice Soup for the Gluten Free Soul

I have been thinking a lot about how I can write about our miscarriage and keep it “on the lighter side.” My primary hope for this blog is for it to be a safe place to come to learn about fertility treatment and our story without having to be burdened with sadness and loss.

There are so many positives to connecting with other women who toil against infertility, but one of the downsides is that when you are close to them you feel their pain as your own. Another is that it is easy to take other’s sad circumstances and fantisize unproductively about them becoming your own. Sometimes it is best to stay away from Dr. Google and his dark, foreboding staff.

Because I believe a positive mental state is critical to managing stress and optimizing odds of success, I decided to limit my interactions with chat rooms and boards in an attempt to surround myself with positive energy for this cycle. While I miss “my girls” tremendously, it has been easier to not be completely obsessed with fertility and of course has given me the time I need to share my story with you in a way I would want it to be shared with me.

The desire to try to lighten the load for you does create quite the conundrum as it relates to finding a way to talk about one of the single most painful events in my life. I am not sure its entirely possible, so take heed as you begin reading this post. I gave it my best shot for you. While the stars aligned in the last 24 hours to give me some great fodder for sewing at least a few seeds of humor around our loss, I am afraid I have failed you and that what follows is not very light at all. I do manage to pepper in just the tiniest bit of levity and a small amount of positivity.

If you read Blown Away yesterday you know that I am away from the loves of my life for work for most of this week. In fact, I didn’t expect to be able to post at all until Friday because of an intense series of meetings scheduled for today and tomorrow. Unfortunately I am not in a meeting and am posting from a bed in a hotel in Lansing where I am recovering from a terrible case of food poisoning that I suspect came from a bad piece of black cod. That will teach me to order fish in landlocked Lansing.

I say its unfortunate but I am not sure I really mean it, its almost better than being at that meeting. If you have ever had food poisoning, you know it is no joke and that this is a strong statement. There was a moment at about 3 AM when I seriously wondered if I was going to live to see today. However I have been poisoned by my grub twice before so I knew if I just hung in there I would eventually be on the other side of the worst of it. I am now there.

Thank. You. God.

And where I am now is NOT in a meeting room in downtown Lansing where I lost a pregnancy back in early July.

Thank. You. God.

Don’t get me wrong, I have been to that meeting room since July and will be there again. I am strong and would have made it through it and probably even enjoyed the meeting with my boss and peers. Probably. But not being there today is definitely a great big fat silver lining to a cloud that will always hang over that place for me. So thank you God for your sense of humor and thank you black cod for choosing the perfect time to poison me.

Our miscarriage story started back in February of 2013 when we began our first IVF cycle for baby number two. We tackled the process with a renewed faith in ourselves and IVF after having Spork the year before. Prior to the fourth transfer that ultimately gave us Spork I never would have thought I could go through another IVF cycle. She was what we needed to regain confidence that we could do it, we could go through it all again. It was worth it.

Our cycle went very well in the beginning. We retrieved more eggs and made more embryos than we ever had before, 10 embryos when it was all said and done. 10 embryos? There had to be a baby in there!

We transfered 3 in the fresh cycle 2 days following retrieval and did not get pregnant. We were disappointed but we were okay. Heck this might even be a good sign! After all we got pregnant on a frozen cycle with Spork and we know that some women do better with frozen cycles. We rationalized that I was one of those women and prepared for the inevitable success that was to come in May. Besides, if it had worked what in the world were we going to do with all those leftover snow babies?

When we discovered our transfer date was the day before Mother’s Day, we were positively beside ourselves with excitement. Spork was transfered to me on Mother’s Day in 2011 and we always considerred it part of the magic that brought our sweet baby girl to us.

Sadly, the magic faded for us after that. When we arrived at the transfer we learned that all 7 remaining embryos had to be thawed in order to get the three we were transfering. It was devastating. Our third chance was taken from us prior to the second chance from this cycle even really beginning. Then to add insult to injury the transfer went very poorly. Having a “smooth” transfer dramatically improves success rates and our transfer was anything but. The reason for this is that I am somewhat anatomically challenged in terms of the way my plumbing is situated. I will spare you the details, but suffice it to say I am difficult for the doctor to navigate. Despite knowing this, he made the mistake of sending his sonographer home and tried to wing it with a nurse. I presume he did this because it was Saturday and we were the last transfer on the schedule. Not cool. Transfer normally takes about 5 minutes and this one took over 20 and involved the doctor yelling and sweating profusely. So not cool.

When we left we wondered if the embryos even made it to the sweet spot and whether there was any chance I could be pregnant from this doozie of a cycle. I was fighting back tears and Bill was shell shocked and angry. So you can imagine our surprise just a few days later when I saw that first little faint hint of a line on the home pregnancy test. Hell yeah! Who needs those other 4 embryos anyway? Our doctor went from zero to hero in a matter of seconds. All that sweating and yelling paid off and he had nailed it.

When the blood test was done a few days later we were stoked to have the confirmation for the home pregnancy test. Our beta HCG level was 60, not too high but certainly high enough to feel reasonably confident we had a healthy pregnancy starting. Two days later it only went to 100. Beta HCG levels are supposed to double every 48 to 72 hours, so this was concerning but did not mean we were out of the game yet. It was right at the outer limit. We waited another 4 days and the levels only went to 160. Uh Oh.

But then 4 days later the levels took off and did exactly what they were supposed to.

Yes! Yes! Yes! We were still worried but hoped that there was a vanishing twin skewing the numbers in the begining and that all would be well from here on in the process.

Because of our slow start we continued to monitor the Beta HCG levels every 2 to 4 days and went in for an ultrasound at 5 1/2 weeks. The ultrasound showed a small gestational sac which was a little on the slow growing side but still had the potential to become a bonafide bouncing baby. We took off the next day for a week in Northern California to attend Bill’s 20th highschool reunion. Having been pregnant before, I could tell toward the end of the trip that something was off but still held out hope that we would see a heartbeat when we returned and had our our next ultrasound. I faithfully awoke to take my progesterone shots at 3 AM Pacific every day (I defintely should have planned my shot time better in light of the trip). I abstained from all alcohol on a trip that was infused with it. I caught myself rubbing my belly in anticipation. We couldn’t wait to get back and find out the results.

The day after we returned home we had the fateful ultrasound that showed at 7 weeks we still only had a small empty sack that measured only 5 weeks and 4 days. There was no fetal pole or yolk sac. Nothing to indicate this pregnancy had the potential to become Spork’s sibling. It was time to stop the meds and hope that my body expelled the pregnany rather than needing a medical intervention to remove it.

When this happens you don’t know when or if you are going to lose the pregnancy naturally so its not as if life can stop while you wait to see what happens. As fate would have it, I lost my pregnancy at exactly 8 weeks over the course of a full day meeting with my boss and peers in that meeting room in Lansing. The one I am supposed to be in right now. It was physically painful. Nobody prepared me for the physical pain. I took 3500 mg of Tylenol over the course of the meeting and unsuccessfully fought back tears the whole day (I didn’t learn until later that this was a dangerous dose of Tylenol, so don’t do this!). After the meeting concluded I had to drive 3 1/2 hours home. There was really nothing very funny about that day. The process of losing the pregnancy continued for nearly a month, but the worst of it happened on that one day in that room.

Once again, shortly after the loss fate intervened to make life a little bit easier for me. My boss’s territory grew which required us to move our monthly meetings to Kalamazoo. Thanks boss! Yes it means more work and travel for him, but I have to believe that its all in service of keeping me away from that meeting room. The one that I will fight back tears everytime we take a break as I open the door to that women’s room where I lost a little part of me.

This month we had to move the meeting back to Lansing, just this one month. Of course in reality I would prefer to be there right now. But there is no way I could sit through a meeting given how I feel. Instead I will take the good with the bad. I am sure I will be back to normal tomorrow which is just fine. I won’t be facing any demons. Fortunately the meeting tomorrow has a bigger audience and will be right downstairs in this hotel.

Ironically, the timing of the cod attack was good for more than just keeping me from opening up that old wound in a very public and challenging setting. One of the silver linings I can’t really talk about. It involves someone I am close to receiving some incredibly shitty but not devastating news that kept me in tears in between trips to the bathroom last night. You know who you are and I love you. Today I am able to deal with that in a way I couldn’t in any meeting room, let alone the one in Lansing.

Also, I took a single dose of an important medication this morning that I was more than a little concerned about taking while in meetings this week. It’s a medication that my new doctor gave me to help me avoid a difficult transfer like the one described in our miscarriage story. The drug is called cytotec and it is the same medication in the same dosage that is used to soften the cervix and induce labor. So I am having small contraction like pains today. These pains will help make it easier to get to the sweet spot on March 13th. Better here than there in that room, that is for sure.

So this afternoon I found myself unexpectedly stuck in a hotel room surrounded by memories, feeling similar phiysical pains as to those of miscarriage, and reeling from a lost battle against a gnarly piece of fish. And amazingly, I was starving. I had no choice but to try to order room service from the very same kitchen that served up that horrible fish last night.

Since I am gluten free I was very skeptical that I would be able to eat at all today. When I called to ask what the soup de jour was, I had a little giggle when they told me it was Chicken and Rice. Not Chicken Noodle. Chicken and Rice. Chicken Noodle just would not do for a sick girl who doesn’t eat gluten. I couldn’t think of a more perfect lunch for a day like today even if it did have to come from Hell’s Kitchen.

It was exactly what I needed. A little Chicken and Rice Soup for the gluten-free soul.

Yes God. I see you smiling on me today through those heavy storm clouds. Thank You. Thank You.

Thank. You. God.