Fresh Transfer | 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.

Ultrasound 2- Day 7 of Stimulation

Today’s scan was good overall. We still have 16 follicles. The same number are measuring in the range we want but the left/right ovary mix changed.

With today’s scan I would have expected the results to be about the same, or maybe even a greater number of follicles. While the numbers overall stayed the same, 7 on the left and 9 on the right, only two were measuring where they should be on the left. However all 9 are now looking good on the right.

So we remain at 11.

Image by Curtis Perry vis Flickr

My left ovary has often been a source of trouble, and my right has historically produced more. However I have never seen the left respond this poorly.

It makes me wonder, did my unhealthy ovary cause the cyst we aspirated or did the aspiration of the cyst cause the unhealthy ovary?

Nearly all the follicles on the right ovary were measuring around 17mm. My estradiol level was 913. Ovulation is typically triggered when four or more follicles are larger than 18mm and estradiol is over 2000. Follicles typically grow about 1-2mm per day during this stage of stimulation. Choosing the exact right time is paramount. Waiting too late or going too early could create problems with egg quality which decreases fertilization rates and embryo quality.

What does all this gobbled gook mean? It means we are closer than I would have thought.

It means we could be pregnant by Wednesday.

Wow. It seems like things are moving lightening fast since we had our failed cycle with Celebrity Miracle Clinic.

Tomorrow night I will make the 3 hour drive down to the clinic for a 7:30 AM ultrasound with the doctor. I should know by midday Saturday when we will trigger.

Bill is staying home with Spork and meeting with clients so I will be flying solo on this quick overnight trip to the clinic. Spending the night alone in a roadside hotel isn’t exactly the way I had planned to spend my Friday night, but I can’t complain. Its worth the trip down to be seen by the doctor so we can all feel good about when to make the decision to trigger. I could choose to continue to monitor locally, but the doctor prefers to see what is going on for himself at this stage.

That’s great and I am all for it, but do you think he will wear green underwear for me?

You may recall that my local sonographer is also a great friend and we threw a baby shower her a few weeks ago. Well, she had her baby on Tuesday and would you believe that her backup person broke out the fertility green lingerie just for little ole me? The ladies decided to switch from fertility orange to fertility green to see if it would bring a change of luck.

I too decided to change things up a bit and switched to orange toes this week. I actually planned to do away with the superstitions altogether since they haven’t been working for me. However when I arrived at the salon I discovered five new shades of orange. One of the fiery selections was called “My Paprika is Hotter than Yours.”

How can you NOT wear that nail polish?

Here’s to hoping it works…

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.

Knocked Up

It’s done!

And yet it begins.

“Blob” as we are calling him (or her) is now resting peacefully at home, preparing to burrow into my lining and take root for the next nine months. It was a harrowing, exciting, and ultimately pleasant experience which began with our wondering whether we would be transferring Blob at all.

Blob’s First Baby Photo

Yesterday at the top of Breck’s Peak Six, I picked up a call from the clinic asking if I could come in right away for a cautionary ultrasound. It seemed the doctor was concerned about my cyst and the pain from the night before. Rather than blow our day of boarding we opted to arrive very early this morning to check on the status of my temperamental reproductive system. Until about 7:30 this morning we feared we would be coming home empty handed (or in this case empty “uterused”). Luckily the lining, ovaries, and vitals all checked out fine and we continued with the embryo transfer.

Our first hurdle overcome.

Next up was the transfer.

Because our ultrasound and lab appointments were at the break of day, we had time to kill before the 11:45 transfer. We spent it at Target where I picked up these groovy lucky socks. These socks were so perfect they jumped into my shopping cart and I was wearing them before we left the parking lot.

Fertility green and orange with the luck of the Irish thrown in for good measure.

So far the knee highs worked their magic.

Ease of transfer is one of the many critical factors that lead to enhanced odds of success. A fundus (top of the uterus) touched by the catheter used to transport the embryo is a lousy precursor for implantation. Much effort goes into making sure the depth and shape of the uterus is understood before the procedure so the doctor can avoid the edges. It’s like that game of Operation we played as kids, except on a fuzzy black and white ultrasound screen with no buzzers to tell you when you screw up.

Image by Mykly Roeventine via Flickr

The doctor gracefully guided our little bundle of cells to the exact right spot without a single hiccup. Dr. S navigated Blob to the sweet spot with the precision of a fighter pilot landing on a aircraft carrier. What makes this feat more impressive is the embryo can barely be seen by the naked eye. Try landing that in a tiny little spot on a computer screen with only a bit of guidance from an ultrasound tech.

Way to go Dr. S.

Catheter releasing Blob in the perfect spot

Another hurdle overcome.

Blob was a busy little fellow this morning and hatched completely out of his shell prior to transfer, earning a final grade of 6BB. When the lab flash froze him after genetic testing back in January the embryologist graded him a 5BB. He’s overachieving already.

You can see the incubator holding Blob who is waiting in the background while we prepare for transfer

Blob’s incubator in the background

You may be wondering, what the heck do those letters and numbers mean?

Embryo grading is a complicated process, but essentially this means Blob was at stage 5 when he was frozen. This is the final blastocyst stage right before he hatches and burrows into the lining. The letters are grades for the inner cell mass (ICM) and the Trophectoderm Epithelium (TE). The ICM is a clump of cells that will eventually become a baby. The TE will grow into the placenta which will replace all the hormones I am taking between 7 and 10 weeks.

6BB is a good quality embryo. 6AA would be perfect. Both are fully capable of becoming future Rhodes Scholars.

Blob as a Rhodes Scholar

Typically an embryo reaches stage 6 on the fifth day after fertilization. Blob started slowly and took six days to get there. This is the main reason Dr. S gave Blob slightly lower odds than other genetically normal embryos. However, Day 6 blastocycsts like Blob fair much better with a frozen cycle like ours. This is due to the surprisingly short window in which the lining is receptive. Unlike in a fresh cycle, in a frozen cycle the doctor can control the timing of the lining receptivity and match it to Blob’s developmental stage, increasing the odds he will stick.

While our overachiever was quick to break out of his shell, he was slow to expand. If you have ever taken a balloon from a warm place out into really cold weather you know it shrivels up and loses its fullness until warmed again. Embryos are the same. They compact when frozen and then begin to expand when warmed. We are slightly concerned that Blob didn’t expand more prior to transfer, but encouraged that he is still developing. Most important, every last one of Blob’s cells survived the warming process.

A final hurdle overcome.

Post transfer I remained on bed rest for an hour before being wheeled to our car. We are now at the hotel where I will spend today and tomorrow at a 45 degree angle, able to rise only to powder my nose. Butler Bill enjoys this part of the process because it is the time he is most involved in IVF. I enjoy abusing my personal butler and make the most of being cared for by the love of my life at this sensitive stage.

If you look hard enough you may be able to see all the way to Blob through those nostrils.

If you look close enough you may be able to see Blob through those nostrils.

Butler Bill will bring me food, water, and medicine for two solid days. I will read, watch stand-up comedy, blog, goof off on the internet, meditate, and try not to obsess about possibilities. I am allowing myself only a half hour with Dr. Google to see what I can learn about slowly expanding embryos. After that half hour I am firing that negative jerk in order to relish being pregnant.

Pregnant.

In the IVF community we describe this part of the cycle as being PUPO (Pregnant Until Proven Otherwise). I am so done with the uncertainty implied by “until proven otherwise.” This mama has decided she is straight up knocked up. I plan to prove it on March 22nd.

Our countdown begins anew…

Shoot Em’ Up

Tomorrow is the day. This addict is tired of only popping a measly little birth control pill every morning. Thankfully the waiting for the good stuff is coming to an end. Tomorrow I begin the real work that will take us towards our March 13th transfer date.

Yes, the time has come when I start shooting up.

I have been waiting with anticipation all weekend for the morning when I start taking Lupron injections. Even though the are small, they are mighty, and the shots are a critical stepping stone that will lead us to the Promised Land.

As I discussed in Addicted to IVF, there is just something about this phase in the cycle that makes the long time IVF gal get excited. Heck, even if it is your first IVF it is thrilling to take that first shot, albeit a little frightening. After all you have so much time, money, hope and energy invested into this part of the process.

And best of all, you finally get to put your Baby in a Box to good use.

What is this Baby in a Box?

When you go through IVF you require a number of different medications for different phases of the cycle. These medications are not your average, every day, run-of-the mill medications. Your local Walgreen’s does not keep them in stock. Therefore they must be ordered through the mail, typically through a specialty pharmacy.

When we start an IVF cycle, all my meds are sent to me in one big box which happens to be about the size of a very large baby. If the meds do what they are supposed to and your body complies you will have a baby in about 10 months or so.

And there you have it, a Baby in a Box.

There are a lot of drugs that do a lot of fun stuff in the box. What you see above is only a portion of it because we are currently only doing a portion of the IVF cycle.

The first phase of an IVF cycle is the stimulation phase. This is what we did back in November when we amped up my body with hormones to help it develop many eggs instead of the usual one per month. The stimulation phase is without a doubt the most grueling part of IVF. It can be quite uncomfortable and culminates in an invasive surgery to remove the eggs. Stimulation is also the most expensive part of the cycle and I am glad for that reason among many others that it is behind us.

Many clinics go straight from stimulation to transferring a fresh embryo back to Mom anywhere from 2 to 6 days after the eggs are retrieved. This is called a “fresh cycle.”

But that is not what we are doing. Not this time.

We are doing what is called a “frozen cycle.” We had the embryos genetically tested which means we had a great big pause between retrieval of the eggs to the part of the process we are now entering, the frozen embryo transfer.

Our embryo is 6 days old, chomosomaly perfect, and is just chilling out in cryofreeze waiting for us to come and get him (or her). Lupron is the first shot we take that will help us prepare to do just that. Its a small dose with a tiny little needle in my belly. This one I give myself because it is pretty painless and easy to administer. It does eventually make my tummy look like it has freckles all over it from the small scars, but those are battle wounds of which I am deeply proud. They do fade eventually.

Lupron, like most hormones involved in reproduction, is a weird dude. It’s short for Leuprolide or Lutenizing hormone (LH). Male and females both use LH to regulate the pituitary gland and control secretions of other hormones like follicle stimulating hormone (the stuff that makes all those eggs develop in the first IVF phase), testosterone, and estradiol. What makes LH weird and kind of cool in my opinion is that in small doses during certain points in a cycle it will down regulate these hormones. Shuts them right up. Quiets the body and limits the hormones secreted.However mid-cycle a large surge of LH (LH surge) will actually trigger ovulation and the resulting production of hormones. This surge is what will cause a home ovulation kit to have a smiley face or a dark line. I find its dual and seemingly contradictory functions fascinating.

Because LH in regular, small doses will slow the production of hormones that can feed certain types of cancers, it is often used in treatment of those cancers. And here is a super fun fact, high doses are sometimes used to chemically castrate sex offenders. Yep. You read that right.

Isn’t that lovely? As if we need another way for fertility treatments to impact the libido, and this one a scientifically proven one. However its somewhat irrelevant because the birth control pill I am on has already zapped what little libido I have at this stage in the process. Ironic that a birth control pill would do that but it does for me and always has.

For me, the main side effect of lupron is uber bitchiness. I mean, “stay out of her way” bitchiness. The mood altering effect of the drug is my primary side effect , but it also causes weight gain and headaches. Massive, horrible, headaches. The weight gain and headaches of course form a mean pair that further fuel the uber bitchiness. It’s not pretty.

Given all this you would think I would be dreading tomorrow, but in fact I am looking forward to it like a kid at Christmas. The Lupron shots I start tomorrow will shut my reproductive system down. This is so my doctor can take over and manipulate it with still other many other hormones that are to come. Its a little like computer that has been rebooted after new software is installed. When my reproductive system comes back online it will have a new operating system controlled by my RE. One more step toward bringing home baby. When you look at it that way, its pretty damn exciting.