egg retrieval | Laughter Through Tears

IVF 102- The Process

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 pretty creative too...

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.

Sweet Sixteen

Holy moly we got sixteen eggs! Im guessing that some are immature since we have been looking at 11 in the normal size range all along, but with any luck we will have fertilized embryos up in the double digits. We also injected HCG in the uterus to increase the odds of our future babies staying for the long term.

Our first hurdle is behind us and now its on to fertilization results. The clinic will call me with the number of embryos tomorrow and our transfer time.

Let the waiting commence!

I am ecstatic, exhausted and laying down for a nap with my sweet girl. Thanks for all your continued prayers and support.

Ultrasound Number 4- Day 11 of Stimulation

The lonesome trip to Grand Rapids last night was uneventful and I managed to stay away from Dr. Google. The scan was this morning was excellent. I still have a total of 8 follicles on the right and 3 on the left. There are a few smaller ones that might come along too. My estradiol level was 2710.

Deciding when to trigger is an art. My ovaries are kind of like an oven right now. If we wait too long the eggs may get burned (over-mature). If we trigger too early the eggs may be undercooked (immature). Neither an immature or over cooked egg would result in an embryo.

Follicle size and estradiol level help the doctor determine the best time possible to start the 38 to 42 hour time clock that ticks down to ovulation. We will schedule retrieval exactly 35 hours after trigger in order to get at the eggs when they are nice and loose and about to come out on their own.

After all this time I still find it hard to believe we have such a very short window to collect the goods before they would eject on their own and disappear into my body unfertilized and wasted. Pretty wild, huh?

Ultimately, we decided to “let it ride” and go one more day to make sure we get as many mature eggs as possible. While my estrogen level is in a great range for trigger, it is low enough that it gives us a little room to see if we can get some of those smaller follicles into the game.

So we will trigger tomorrow tonight for a retrieval on Thursday. Friday we will inject HCG into my uterus to prepare it to receive our embryos.

Saturday will be the big day!

This makes three cycles in a row that we stimulated for 11 days. Ironically, last time with Home Clinic we had 11 mature eggs. At Celebrity Miracle Clinic we had 11 embryos.

Eleven seems to be our number. Let’s hope its lucky this time. Maybe I should go play craps or roulette or something.

Image by Ben Harrison via Flickr

On the balance, I feel really good physically even though I already look pregnant from all the bloating. I felt like absolute crap far sooner in all my previous cycles. With the exception of the cytotec induced night from hell, this has been my smoothest cycle ever. My body seems to be handling the stress much better than in the past which I pray means higher odds of a fresh transfer sticking for us.

Gosh let’s hope so.

Mama needs a new pair of (baby) shoes!

IVF 101- The Players

This blog exists mostly as a way for me to fuel my never-ending obsession with getting pregnant. But its not the only reason. I blog to help other couples dealing with infertility. I blog to educate those who are not going through this journey to give them a little glimpse into this world so they can help those imprisoned in it .

For most of you, a post describing the basics stages of IVF will be all too familiar and remedial. If that is true for you, stop for a moment and think about it. Do you remember that almost-impossible-to-recall time when you didn’t know everything about IVF? When you had to ask what IVF stood for? This article is for those who still retain that blissful ignorance and for those that love and want to understand them.

So for those who don’t know, IVF stands for In Vitro Fertlization, which is Latin for fertilization that takes place in vitro or outside of the body. You would think that since the the first test tube baby was born fairly recently in 1978, we could just drop the fancy Latin and call it HMC for “Hail Mary Conception ” or LDE “Last Ditch Effort.” After all, it is the final option couples explore when trying to conceive, usually after trying everything else. But like everything with IVF, its too intricate for a simple and descriptive name. IVF is complicated on every measurable level beginning with the number of people involved in the process.

Your Baby Dream Team- The Players

Reproductive Endocrinologist– Your main dude or dudette. He creates your treatment plan, makes adjustments to your medication, and will perform your retrieval and transfer. In some smaller clinics you interact with your RE frequently and he is actively involved in regular discussions with you. In larger clinics you never see your RE and even need to schedule time with him to ask questions. Some clinics actually have the audacity to charge for consultation time with the RE if it is outside of the regular communication plan. I have been billed only twice for consultations at two different clinics. In both cases I called and had it waived. Always remember you are the patient, which means you are paying the bills and have a right to your information and feedback from your doctor. Most RE’s are terrific, but if that is not what you experience use your voice. It also helps if you try to pack as much into your planned communication with your doctor and come prepared. Many clinics have multiple REs so the person you consult with may not be the one who performs your procedures depending on timing.

Embryologist– Your embryo’s main dude or dudette. She manages the lab and takes care of the eggs once your RE retrieves them. She and her team are the lucky ones who get to create the life by joining your eggs and sperm, and then monitor them as they grow into embryos. She also manages the storage process in the event you need to freeze your would-be-babies for later. In most clinics you rarely interact directly with the Embryologist. Sometimes she will call you with fertilization or embryo quality results, but in many offices the nurses or RE handle that. She will be present at transfer to assist the RE in getting your embryos from point A to point B. Like REs, many clinics have multiple embryologists.

Nurses– Your translators and best friends. They speak fluent Reproductive Endocrinoligist and will be the people you interact with most often. They order your meds, take your frantic calls, tell you when to take what and will even show you how. Because they regularly deal with desperate women who are hopped up on hormones, they may very well be the most patient and wonderful people on the planet. Some clinics assign you one nurse who helps you manage your plan, while some take more of a triage approach where you work with whoever is available. There are advantages and disadvantages to both. If you are using donor eggs, there will usually be special nurses to work with you and your donor to coordinate communication and timing.

Sonographers (ultrasound techs)- Your examiners. These people will regularly violate you with a large wand to determine if your lining is thick enough and has the right number of layers (three!) for transfer. They also monitor the size of your ovaries and the number and size of your egg containing follicles through the course of your IVF cycle. Once you start taking medications to stimulate the ovaries you will see the sonographer every two to three days. When you are close to retrieval your appointments may be daily. They will also monitor your pregnancy until you graduate to a plain old obstetrician at about 10 to 12 weeks. In some clinics, nurses are trained techs and also perform this function. Its worth noting that for a sonographer, a trans-vaginal follicular ultrasound is the most complicated test that they do. It’s like Rodney Dangerfield’s Triple Lindy for sonographers. Your tech will be trying to count and concentrate which usually means their eyes are squinted and their mouths are open. This is normal and does not mean anything is wrong. Let them do their thing and then ask them questions when they are done. Its hard work and I have only met a few that can carry on a conversation while performing a follicular scan.

Third Parties– Your saviors. In the event that you need to use someone else’s “stuff” to get knocked up you may find yourself working with a surrogate, gestational carrier, egg donor, or sperm donor. Even people that use gestational carriers and surrogates get confused on the difference. A surrogate is a saint of a woman who will give you both her eggs and her body. A gestational carrier is a saint of a woman who will give you only her body, you have to provide the eggs.

Pharmacy– Your dealer. Fertility drugs are not your average, every day, run-of-the-mill medications. You cannot find most of what you will need at your local Rite Aid or Walgreens. Instead you will need to use a specialty pharmacy. There are several national chains and larger cities will also have local options. Without insurance, the medications can run up to as much as $6000 per cycle for women who need a lot of juice to get their reproductive system to react. Prices vary a great deal and its worth the time and annoyance to call around and get quotes on the more expensive medications. For instance, I found that one pharmacy offered the HCG trigger shot for $88 while another charged $250. Shop around and ask about rebate programs if you self-pay.

Phlebotomist– Your own personal vampire. If you are undergoing IVF you are probably no stranger to the phlebotomist but you are about to potentially add her to your Christmas list given how much time you will spend with her. In some clinics, nurses also draw labs. Some clinics have you visit a third party lab for blood draws. Wherever you go, you will likely have blood work done every time you have an ultrasound or diagnostic appointment. Just accept the fact that you will look like a heroin addict by the time you get knocked up. And take it from me, don’t volunteer to allow someone in training use your veins for practice. They can learn on happy pregnant people who don’t have to do this every other day. Trust me on this one, you are not being mean. Just say no.

Image by Thirteen of Clubs via Flickr

Counselor– Your lifeline. Most clinics have someone on staff available to you and your partner for free. Many clinics even host support groups for patients. I strongly encourage you to take advantage of this if it is available to you. Even for the strongest of us, IVF is emotional torture and the process is especially hard on relationships. These people have tools that can help you cope that may or may not increase your odds of success, but even if they don’t directly help you conceive, I guarantee they will increase the odds of your relationship surviving IVF. Don’t wait until you feel like you need it. Start dealing with your volatile emotions now.

Billing– Your necessary evil. These people will work with your insurance if you have coverage to make sure as much is covered as possible. They are also Gestapo like in their ability to put fear into you if you are not up to date on your payments prior to your procedures. Nothing can throw a wrench into your baby making plans like having a treatment threatened to be cancelled until you pony up some cash. Stay up to date on your payments, but more importantly spend time with them in the beginning to ensure you understand all your options and the full costs. Many clinics offer special packages for those who qualify and one of my biggest regrets is not exploring options when I was young enough to take advantage of them.

That is your dream team. Hopefully it helps you understand why your clinic might make you feel a little bit like a football that is being thrown back and forth. Sometimes it seems like there is very little forward motion, but don’t let that deceive you. All of these people are on your side and are working hard to take some yards against infertility and arrive at your joint goal of having a healthy baby. IVF is complicated. Because of this you need a number of people who specialize in small parts of it to help you along the way. It may feel clunky and disconnected at times as a result, but its part of the process.

Image by Mark McGee via Flickr

Ultimately though, you are the most important member of your dream team. Its important for you to understand the process, learn about IVF, and question your team when appropriate. While all these people are working for you, nobody cares about your success the way that you do. And mistakes do happen. I have run out of medications on the weekend, not knowing the clinic expected me to know I needed more meds when my dosages were increased. I have experienced nurses failing to order meds and even certain procedures. I even had a pharmacy send a refrigerated medication using regular ground transportation and it was ruined by the time it arrived. Stuff happens and you have to be vigilant to avoid letting it throw off your cycle.

You are your own best advocate in a complicated process, which we discuss in more detail in IVF 102- The Process.

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.

Begin at the Beginning

When I began my last post about infertility and insurance I had no idea I was going to go down that path. The post was supposed to be about something completely different, but then I found myself following a new train of thought that has now led to a whole series of posts I have planned. That’s what I love about blogging and what makes it so cathartic, it helps you uncover and work through feelings and thoughts you didn’t even know you had.

The insurance post began by highlighting one of the few positive outcomes of our last failed cycle. With more than a little sarcasm I began with a discussion of our tax savings due to our hellacious IVF spend in 2013. It was intended to simply be a preface that led to a broader discussion about another benefit of our last failed cycle, one that I am less sarcastic about than giving a doctor tens of thousands of bucks just to save a bit on what we give Uncle Sam.

The other benefit I am eluding to is that now we can begin at the beginning.

When we started this blog, we were already in the middle, waiting to do a frozen embryo transfer back in January. We were in the last leg of a long journey with one of the best clinics in the country. We had already completed the most intense and challenging part of IVF. So much had already happened that we did not have the opportunity to share and explain. Now we have that opportunity.

I always planned to go back to the beginning and describe the stimulation process, retrieval, and how we prepared for and experienced both regardless of whether or not the last transfer stuck. One of my hopes for this site is to build a repository of information based on real life experiences so that those in search of information can find it here anytime. While I could do this based on memory, there is nothing quite like documenting experiences as they occur in real time.

Sure I would rather be pregnant right now, but since that didn’t happen I will just have to settle for the blog being slightly more interesting and helpful for other infertiles.

The beginning, the whole IVF process from start to finish, officially kicks off tomorrow when we have our consultation with New/Old clinic. This is kind of a big deal because we live in a rural area and our clinic is over three hours away which means a whole day off work to fit in an hour long discussion. As a result of the distance we have our monitoring done locally so this is one of only a handful of times we will be there in person and can look our Miracle Man in the eye to ask him the tough stuff.

I have my usual list of twenty questions ready for Miracle Man and saved in my phone. By tomorrow night we will have our official plan and will have taken an important step toward a sibling for Spork. Friday our “Baby in a Box” will be delivered to our door. As is always the case at this stage, our sadness has all but lifted and we are growing hopeful, anxious, and excited about this next step.

Stay tuned, wish us luck, and enjoy.

P.S. I still don’t have a name that feels right for “New/Old Clinic” so for now that is it. If one strikes me that fits I will let you know.

Waiting- Part 1

Image: Denise Curran via Flickr

For many, waiting is a as much a part of trying to conceive as sex. When sex is removed from the equation for the couple trying to conceive through IVF, waiting becomes the single most frequent conception act. Waiting, just like its more provocative cousin, can come in many flavors and is done throughout the IVF odyssey.

The big waits are obvious. The most mammoth is the wait between the time the embryo is transferred and the results of the Beta HCG pregnancy test. In our case, this wait spans nine intolerably long days. Time moves very slowly over the course of what is commonly called the two week wait. I’ve often heard women say it would be just fine to be unconscious during this time and awoken only after the results are received.

March 13th is the date of our transfer which means on March 22nd we will have the eagerly anticipated results. The date is circled on the calendar. The hope and anxiety are already building.

The torture of the two week wait is followed in magnitude only by the wait a couple experiences between the egg retrieval and the final fertilization report. Money, hope, health, and mental well being are all riding on discovering whether the eggs fertilize and grow to a stage and quality acceptable to transfer and make a baby. Being sadistic people by nature, we chose to extend this period at our new clinic by throwing a little genetic testing into the mix. The time it took from retrieval to receiving the call that we had genetically normal embryos to transfer extended over 3 weeks.

Waiting for the genetic results is further broken down into waits that are much smaller. We experienced almost immediate gratification after retrieval and waited only two hours to learn that 22 eggs were retrieved successfully. The clinic then called 24 hours later to tell us that 12 of those eggs were mature and 11 fertilized. These were minuscule intervals in comparison to what came next. For the next six days we patiently but eagerly waited to be told that 5 of those embryos made it to the blastocyst stage and were good enough quality to be genetically tested. Next we waited two and a half weeks to learn we had two genetically normal embryos and two that needed to be retested, therefore requiring yet another two week wait. Our embryos were on my mind every spare moment during this time. Ultimately we ended up with three genetically normal embryos. Our last is the one we will transfer in March.

The longest wait of all was this summer and fall while we waited to work through a long process at our clinic that would culminate in our embryo transfer just last month. We first called in June and were able to meet with our new doctor in July. This was followed by another month long wait to get on the calendar to visit the clinic for our work-up to make sure we had a green light to begin our cycle. By November my ovaries were finally percolating and we flew back to our clinic again for egg retrieval surgery. After retrieval the wait was another two months as we completed testing on the embryos. In the months preceding retrieval we used the time to get our eggs and sperm ready to do their life’s work. We each took different supplements, limited alcohol, exercised moderately and ate healthy. At my peak I was taking 19 different supplements a day and Bill took 11. At least it helped us pass the time.

Tiny little waiting periods pepper the whole IVF process. Since our failed cycle back in January I have waited three days to get my period, three more days to start birth control, another 13 days to start lupron, and five more days to once again stop the pill. Each step takes us a little bit closer to our fate, whatever it may be. Though small in terms of actual time, these steps feel gigantic. When they come early, it can be unequivocally thrilling. And that is what happened today.

If you read a Deeply Disturbing Fascination with Toilet Paper you know a little bit about the waiting for that happens for a woman who is getting ready to start a frozen embryo transfer or other cycle. Since Saturday I have been a devoted student of TP. Today I hit pay dirt and was able to call my clinic to check off a critical step that will take us to transfer. Two days from now I will begin estrogen patches that will prime my uterine lining. I continue administering lupron daily but cut the dosage which should help with the headaches and other symptoms. Sadly the bitchiness caused by lupron will only be replaced by the emotionality of estrogen. The end result for me is about the same. Say a little prayer for Bill who catches the worst of the mood swings.

My call to the clinic today was a full day earlier than we all expected. However, no changes will be made to the transfer date. The lupron I am injecting keeps my reproductive system suppressed and on schedule. The extra day may only serve to give my lining just a tad bit of extra thickness to welcome our embryo home. A nice, thick, cozy lining should help that embryo want to stay for the long haul. With a little luck we will then be waiting for doubling HCG levels, morning sickness to pass, a myriad of ultrasounds, and ultimately a scheduled C-section date.

Even though meeting today’s milestone early will have no impact on when we actually get pregnant, it is a rare event to have something, anything come early. I’ll take it.