Our “Heaven Sent” Baby Shower

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Heaven sent banner with angel onesies. Onesies have angel wings on the back which we can now use as photo props.

 

Our shower was way back in October but this is the first opportunity I have found to upload photos. This is ironic, because at this very moment I am typing with one twin on my chest and one next to me in the crib. More detail to come on that in a later post!

My sisters and Mom put the small event together very early in my pregnancy (21 weeks!) because I had a complicated pregnancy with my daughter Evie and I was sure it would be the same with twins. After all it was a high risk pregnancy and I am almost 40. From day one I mentally prepared for preemies and an uphill battle.

But once again, God had his arms around us and we were able to make it to 38 weeks. I am still amazed that I was able to deliver perfect twin babies with no NICU time necessary.

This is simply more proof that these babies were “Heaven Sent” which was the theme of the shower. My sister Cassie, better known as “Momma Cas the Pinterest Queen,” designed nearly everything and corralled the help of sister Kelly and Mom Bonnie to pull it all together into an event that I think represents her best work yet. As you can see they put love and care into every beautiful detail.

Thanks ladies. It was perfect!

The shower was a brunch complete with chicken and waffles finger food.

The shower was a brunch complete with chicken and waffles finger food.

 

Mimosas anyone?

Mimosas anyone?

 

Heavenly divinity cookies

Heavenly divinity cookies

 

Twins in their watermelon bassinets

Twins in their watermelon bassinets courtesy of my Mom

 

Clothespin game for the twins. I lost mine in the first 20 minutes or so.

Clothespin game for the twins. I lost mine in the first 20 minutes or so.

 

Party favors for guests

Party favors for guests

 

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Homemade gourmet popcorn

 

My favorite party favor

My favorite party favor, and perhaps my favorite part of the shower too

 

Homemade cake courtesy of sister Cassie

Homemade cake courtesy of sister Cassie

 

Gifts for "The Price is Right" and "Clothspin" games

Gifts for “The Price is Right” and “Clothspin” games

 

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“The Price is Right” game

Life is Stinking Hilarious

Back in January, in one of my very first posts, I wrote about being a Rebel in a Bathtub,  describing all the taboo ways I exercise my freedom after a failed cycle. Shortly after writing that post I began to feel old and desperate, overwhelmed by the sound of a ticking clock in my brain, and I decided it would be wise to start following the rules again, which I have pretty much stuck to the last few months. I haven’t exactly been a t-totaller, but I have limited my alcohol, eaten healthy, moderated exercise, and popped hundreds of supplements. I had only three glasses of wine when I learned of Blob’s demise and only 9 total over the course of two months preparing for our last failed cycle.

All that effort at purity and perfection came to a halt last night when I accidentally had way to much to drink which also led to other choices that are not too great for my upcoming cycle like eating gluten. Actually, I didn’t just eat gluten, that would be understating it. Rather, I had gluten with a side of gluten and a little gluten sprinkled on top for good measure. There is more that I did and shouldn’t have, but not that I can put in writing for the fear of losing my low insurance rates.

Today I awoke in a haze and when the memories came rushing back I instantly began hating myself and my youngest sister for the influence that inspired my bad choices. I belly ached to my husband, sharing my self loathing, and also posted to my favorite fertility board about my transgressions. My IVF pals and husband all said the same thing, one night of bad choices is not going to lead to a failed cycle and it might even be good for me. I am human after all and loads of women get pregnant every day in much worse condition.

They are probably right. At least that is what I am choosing to believe. Besides, I can’t change it and its not as if stressing about whether I have destroyed good eggs is going to help me get pregnant. Better to move on and use my guilt for something good, like a run.

While I was punishing myself and trying to eliminate toxins on that run this morning, it occurred to me how ironic life is. There was a time many years ago that bad choices while under the influence might have led to, gasp, a pregnancy that we didn’t plan and didn’t want yet. Fast forward a decade and here I am hoping that the bad choices, which really weren’t all that bad, will keep me from getting pregnant.

Very funny life. Very funny.

And here is another really funny thing about life. It has a way of moving at the speed of light when you want to savor it, but gets stuck in molasses when you are looking forward to something. Tomorrow we meet with our new fertility doctor over Skype and it seems like time has come to a stand-still as I anxiously await his counsel. This is the first time I have ever experienced anxiety about a meeting because we have reached the point with my age and history that being turned down by a clinic is a real possibility. Bill thinks I am crazy, and that just like Celebrity Miracle clinic they will gladly take our money especially given the fact that we still produce so many eggs and conjured up three genetically normal embryos in our cycle late last year. Still after five fresh IVFs and 9 transfers they may advise us to move on to donor eggs. We will find out tomorrow, if tomorrow ever comes.

Image by rubyblossom via Flickr

Image by rubyblossom via Flickr

Meanwhile, my daughter is far too rapidly making the transition from toddler to little girl. Today when I put her down for a nap she did not want to say “good night” to the owls painted on her bedroom door, our routine since she was born. She also did not want to give me “one more kiss and one more hug” like she always asks after I rub her back and sing her one song. She has become a master procrastinator and manipulator at nap time which only further demonstrates how un-baby-like she is. We couldn’t possibly be having any more fun but the arms on the clock measuring our time with her are whizzing around and around leaving memories of my baby in a beautiful but painful blur.

Very funny life. Very funny.

 

*I finally picked back up on reading the book “Writing Tools” and posting samples of my work on the Writing Tools page. Hence the extraordinarily long second sentence in this post. It has proven very difficult to keep up my work on writing skills while in the midst of IVF but now that we have entered a waiting period I hope to be able to work on it and add posts on most weekends.

 

Dear Sarah

Dear Sarah,

I am writing you this letter because through many years and hundreds of conversations I still haven’t found a way to say to you what I need to say and think you need to hear. I don’t know why this is so hard for me, you would think that after all I have been through it would be easy for me to tell you not to wait, not to do what I did and let precious fertile years slip away. After hundreds of shots, tests, ultrasounds, and buckets of tears I should be screaming at you “Don’t wait! You can’t wait. The most fulfilling and beautiful experience a woman can have is slowly creeping out of your reach and you have to do something about it NOW.”

But I don’t do that. Somehow I can’t ever find the words, not matter how hard I try.

I have danced around the topic many times and I know you share my discomfort when I do. You tell me you will be okay either way. You can imagine a life with kids and can also see a life without and that either can be great. Like me, you went to school, experienced life, began a career that you loved, and haven’t felt like the time was right to have children. And of course you want to find that person, the one who makes you long to carry a child. I understand, life just hasn’t come together in the right way to make you a mother yet, or even to allow you to give it too much thought. It seems so distant, so impossible and foreign, even if you feel that natural drive pushing you toward doing what you were made to do.

I remember the feeling well. There was a time in my life I wasn’t even sure that I wanted children. And then at 34 I had a moment that changed that, a moment that many women have and that you too may have someday. The moment is different for us all and doesn’t happen for everyone, but it does happen for many women like us.

After that moment, all I wanted was to be pregnant and to give birth. So we started trying. I had no idea that I was about to wrestle with demons that, up until that time, I didn’t even know or care existed.

And how would I know those demons were waiting in the dark shadows of infertility when celebrities all around me were popping out babies in their mid-forties? I didn’t know then and chances are you don’t know now that there is a damn good chance that those babies carry the DNA of much younger women and are born of expensive, invasive, and emotionally difficult procedures.

Chances are you don’t know that fertility takes a nose dive at 32 and not at 35 like you have always heard. You heard that because long ago we only measured in 5 year increments but today we know more, a lot more, and we know that we are losing valuable time. Sadly, for most bright, ambitious, and driven women like you, your early thirties arrive before you are even the “you” that you want to be before you are ready to become two or especially three.

I am lucky and thankful every day that we started when we did. After multiple heart wrenching, physically taxing, financially draining, and emotionally painful procedures we had our little girl and I have never been the same. I am sure you are right, life without her could indeed be very good, but I have no doubt hat it is better with her. She is love, pain, joy, fear, purpose, and every human emotion in technicolor. I couldn’t breathe without her and I don’t even remember what mattered to me before her. I am smitten, turned upside down and inside out, and its wonderful.

I want that for you if you want it. And I want you to understand what you may need to do to get it, because if I don’t tell you I don’t know who will.

I am thankful every day that we started when we did, right at the peak of the steep slope of declining fertility. Four years later in our quest for a sibling, the fight is even harder and we are unsure if we will win it this time. Looking back, I wish I had created more young embryos and stored them before transferring the one that gave us our daughter. Or I wish we had made embryos right after we were married and put them on ice for awhile until we were ready to try for the first time.

Better yet, I wish I could talk to my 25 year old self and tell her to go through the slightly expensive but highly effective process of preserving her fertility through egg freezing.

Twenty-five year old me would have thought I was completely insane, because she had time and wasn’t even sure she wanted a baby. I know she would never have done it. Why spend all that time and energy on something she might not even need during a time in her life when she felt like she had way more time than money?

That’s the reaction I expect from you too and its the reason I haven’t said all this to you before. After all, I don’t like it when people tell me to “just relax” or give me other unsolicited advice about my fertility. Who am I to presume that you want or need to know this? Who am I to tell you that even if you aren’t ready you should talk to a specialist, get a few tests done, and consider your options for preserving your fertility even if you may never decide you want a child?

You may not need any of this. Fertility is different for everyone and some women can and do get pregnant in their late 30s and early forties, Its just  not nearly as common as popular culture makes it seem. I want you to know that. I want you to make an educated decision about one of the most important and amazing choices we make as a woman.

I want you to know because I wish someone had been brave enough to tell me.

So who am I to say such things to you, Sarah?

I am a woman, mother, friend, and an advocate. But above all else I am someone who loves you.

All My Best and Love,

Alisa

 

*Image by William Arthur Fine Stationary via Flickr

Follicle Envy

I wrote in Confessions of a Sister and Fellow Infertile that I feel like the odd barren woman out when it comes to the jealousy that often accompanies infertility. You see, I am largely immune to it. Sure I get that momentary pang in my chest when I pass a pregnant woman or see an infant, but for the most part I look at other’s pregnancy success as a huge accomplishment and I don’t let it bother me.

That is with the exception of family and other infertiles. In both those cases I glow as green as the the Jolly Green Giant exposed to radiation in a massive nuclear meltdown.

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In my first post I described my heartache at being beaten to motherhood by those closest to me, my sister and my sister-in-law. In this one I will share a much more light-hearted but never-the-less true confession, I am wildly envious of my closest sisters in infertility.

Now don’t get me wrong, the only time I have ever cried tears over one of these women is when the “joy sucker” known as infertility kicks them in the uterus when they are already down. While I was pregnant with Spork, I felt total despair and cried buckets of tears for a dear online friend who lost twin boys only a few days after giving birth to them too soon.

Last year, I died a little bit inside when one of the first women I cycled with lost her baby to a miscarriage while she was struggling through a shift at work. I love these women and the community that surrounds us through this unfair, sometimes defeating, and otherwise lonely battle. I don’t know what I would do without them.

But…

I suffer from extreme follicle envy. Not pregnancy or baby envy, follicle envy. I am fine with pregnancy and babies. In fact, I am seriously geeked when my infertile friends have strong positive beta results or climb back from no man’s land when a beta or a baby’s heart beat rallies and defeats the odds. I never, ever, envy that moment when they achieve their long anticipated dreams.

Now that is not to say that like most infertile women I don’t sometimes secretly wonder if they got my winning ticket in the baby lottery. After all, only a certain percentage of us IVFers will get pregnant. But I am smart enough to know that their success is independent of my own and does not mean imminent  failure for me.

No, I don’t want their pregnancy tests with their two bright pink lines any more that I want their babies.

I just desperately desire their follicles.

Oh, and their textbook blastocysts too.

I want to have a follicle count that consistently hits in the 20s and embryos that are perfect quality and number in the double digits. I want enough embryos to “go to blast” with confidence. I long for those blasts to get there by day five and earn perfect 5AA grades.

I’ve never had that. My embryos are often fewer in number, a little slower and are average quality. If my embryos were in a beauty pageant, they would be like the smartest girl in high school standing next to all the Victoria Secret’s models all glammed up and ready to hit the runway. Sure mine are pretty enough and hopefully worthy in a way that really matters, but they are usually outdone in both number and physical beauty.

Even though it is illogical, there is no limit to my envy. Even when I know someone’s Reproductive Endocrinologist has overdone it, producing too many follicles and risking OHSS, I want to be in their stirrups. I want that basket full of eggs because what it really represents is a basket full of options, a veritable guarantee that a baby is in their future.*

Its nothing I could or would ever cry over, and just as it is with my family, deep down inside I am genuinely pulling for my infertile friends. When I hear of their fantastic results, it just hurts a little bit as I realize that those days have passed for me and my hopes of having a beautiful blast that grows into a baby will be realized a few embryos at a time and possibly over many cycles. I have to travel the long hard road and may be looking down the barrel at…wait for it… donors eggs.

Donors egg cyclers are not spared my envy either, however, with their young cycle buddies who also often have a lot of follicles and blastocysts. Plus this group has like the best odds of us all and they have already made that emotional and mental leap that I am still fighting against. What’s not to envy?*

Speaking of young, I really think its the young part that gets me if I am totally honest with myself.

I say this because the infertile women who really cause the little lump in my throat when I read their updates are the really young women who knock it out of the park on their first at bat. I wouldn’t have it any other way, but I have seen so many of them join the infertility community and leave it before the pee is dry on that first positive pregnancy test.* I am happy for them, glad they will not have a need to build bonds with others the way I have after years and multiple treatments. And I am glad to be there for them too. Because I think they need me and others like me, if only for a short while.

I remember back when I started IVF.  I was so nervous about posting for the very first time on my first infertility board. So many of the women there were so knowledge and slightly intimidating to me at the time. Here I was having to look up what BFP meant (Big Fat Positive) and they were talking about new technology and protocols and donor eggs, and blastocysts, and it all made my head spin. But I wanted to be a part of it and every time one of them got pregnant it made my heart almost explode with happiness. They were proof it could happen for anyone. It could be me someday.  And of course it was. I have a beautiful baby. I got lucky.

But I am back here now, and I am one of those older “been there done that” ladies. A veteran of the war against infertility back on the front lines to fight again. Only now I am older and battle scarred. I am so weary and some days I just want to stop the fight. But I can’t stop the fight, not now and not ever. Because even if I were done fighting for me I would still need to fight for them.

So maybe that is what this follicle envy is all about. Its not about follicles, or embryos, or low FSH levels. Its not about odds or blastocysts or numbers.

Maybe its all about growing older, being jaded and battle worn.

Maybe I am just longing for the good ole’ days when I didn’t know better and I got lucky in spite of myself and my naiveté.

Whatever it is, I do love the infertile community and everyone in it. Old, young, gay, straight, married, single, male factor, tubal issues… whatever brought you here I am sorry you are here, but I am glad we are here together.

Still… I do sometimes wish I had your follicles and your beautiful blasts. Sorry for that one little detail.

 

 

 

 

 * Yes I know infertility is not resolved by a first successful pregnancy, I am exaggerating for effect.

*studies actually show that too many eggs can impact quality, so it may not be all its cracked up to be, but still its hard not to want it.

*I know the decision to move to donor eggs is hard. I am not making light of it, I am once again just exaggerating for effect.

 

Confessions of a Sister and Fellow Infertile

Image by Alison young via Flickr

Image by Alison young via Flickr

I always thought I was different than many of the women I know when it comes to infertility and jealousy. I never struggle in the same way others sometimes do when I learn of someone’s pregnancy or happen to walk by a glowing Mom-to-be on the street.

Like anyone trying to conceive, my awareness of pregnant women and babies is elevated when I am actively cycling. I am human after all. Because I am in the middle of the two week wait, I currently feel trapped in a fictional and terribly done B movie that plays in my head called “Invasion of the Baby Makers.” Pregnant women and infants are everywhere I turn, and of course I feel that tiny pang in the center of my chest when I see them, especially when I am unprepared to bump into… well… a bump.

But that’s it. The good fortune of strangers as evidenced by their tight round bellies rarely elicits more than that little stab of feeling that sinks rapidly and deeply into my heart but fades as quickly as it came. You may recognize the feeling, it lasts only a moment. And that feeling is about the extent of it. I do not have break downs, cry, or break out the Ben and Jerry’s when I find out someone is pregnant or receive an invite to a baby shower from a lucky friend or acquaintance. I never have.

I always remind myself that I don’t want their baby, I want our baby. Besides, I tell myself, I don’t know what version of hell they may have faced or demons they had to slay to achieve their blissful full-bellied state. For all I know the path they tread could have been as long and hard as my own, so I generally just let it go.

Generally.  There are two notable exceptions. Family and fellow infertile women.

I will talk about my illogical envy for other infertile women in my next post, Follicle Envy, but my issues with family members who get knocked up is really quite strange and deserves a post all its own.

Of course the baby blessings of my family members genuinely make me happy, but a few years back when I learned of my sister-in-law’s unexpected pregnancy only a few days after a failed cycle, I sobbed in Bill’s arms until I ran out of tears. I did this despite the fact she was 37 years old and I had been mortally terrified up until then that she would never have the kids I knew she desired. To this day I still do not know why it upset me so much, but it did. It was probably as simple as timing, as well as the fact that it came so easily to her when we tried so hard for so long.

Then there was my middle sister’s first pregnancy. She literally got pregnant as soon as she started trying and announced it to me and the rest of the immediate family in a pretty dramatic an unexpected way while we were in the two week wait of our very first IVF cycle. I am sure its not a choice she would make today knowing what we all know about infertility and IVF. Back then we were all so naive so certain IVF would work and work quickly.

Once again, I was happy for her but I ached at the thought that I was the much older sister and should have been first. I also envied the confidence she had which allowed her to announce her pregnancy with such utter excitement at only 5 weeks. I already knew then that any pregnancy I had would always have a small cloud of fear over it that would prevent my joy from emanating so purely.

In the back of my mind, I also wondered if she was deliberately trying to beat me to the punch since she knew we had just completed our first cycle. I know now that wasn’t the case, she was just expressing unbridled bliss of the greatest news any hopeful mother-to-be can receive, but try to tell that to a hormone crazed woman in the two week wait. It was painful. The experience was almost as painful as being invited to her shower for her second child while I was going through my first and hopefully only miscarriage.

I already had my daughter then, but it still stung and made me want to crawl under the covers and sleep through the nightmare of her pregnancy that was timed so inconveniently with my loss.

These three pregnancies are the only ones ever to cause me real pain or tears. I am sure there is some psychological reason why only those I am closest to make me to feel the jealousy and despair my other infertile friends seem to reserve for catty women at work that they didn’t like that much in the first place.

Maybe it is as simple as proximity, knowing I would be reminded of what they have and I couldn’t every time I connected with them or anyone in the family. I don’t know. But it ached. Thankfully I think its done for awhile. I am happy for that. But I am even happier to have my beautiful nieces and amazing nephew.

While it was hard at the time I would never consider having it any other way.

 

Calgon, Take Me Away…

Many of you trying to conceive are probably too young to know the old Calgon commercials but I remember them well. After all, I am an old lady trying to get pregnant so there are many things I recall from the late 70s and early 80s. Some things, like Calgon, I remember fondly. Others I would much rather forget, like nearly all the clothing and hairstyles.

The Calgon commercials stuck with me to adulthood and just like the lady in the commercial, I view a good hot bath as the epitome of luxury and the perfect way to escape from absolute chaos.

Man, I could use a good bath right now.

Too bad its not allowed.

Ironically, my doctor told me yesterday after transfer to think of today as a “Spa Day.”  The clinic has relaxed their bed rest policy which formerly required two full days of remaining reclined. Now only one day of bed rest is required and the day after transfer is supposed to be light activity, no lifting, no work.

No problem. Except that I am borderline OCD and also have a toddler.

I did a pretty good job of relaxing at first. I even took a nap this afternoon.

The only problem is that my husband can’t keep up with everything on his own, and I can’t relax when there are suitcases filled with dirty laundry in our entryway and toys scattered all over the floor. Even if Bill could stay on top of everything, he has a different definition of clean than I do. The man is actually capable of weaving his way through an obstacle course of dolls, coloring books, and tea cups. Walking right by a pile of laundry doesn’t even phase him.

So this evening, the Spa day came to a screeching halt.  I cleaned. I did laundry. I couldn’t help myself.

And it wasn’t just the Spa Day that was an epic fail.  I also failed at keeping Spork from climbing all over me with her bony knees and elbows that have a funny way of finding my uterus over, and over, and over again.

Oh well. Normal people get pregnant under much worse conditions.

But I will say this, while I hope this is the last transfer we will need, if there is a next time I am getting on a plane to Mexico the day after transfer.  Alone. And with nothing but a swimsuit, a pair of yoga pants, and a t-shirt.

Done.

Image by Dawn Nakaya via Flickr

Image by Dawn Nakaya via Flickr

Speaking of a potential “next time”… when we were discussing the quality of our embryos yesterday I told the RE that I thought I had one more try left in me if this didn’t pan out. His response was “we can talk about that.”

Huh??? What exactly does that mean?

I think that means he’s going to start talking donor eggs if this doesn’t work. Bill, the eternal optimist, thinks it means he will try to convince us that it may take a few more tries.

Ahhhh… my messy, sweet, and positive husband. I love him so. He actually told me today that he thought the transfer must have worked because I had a “glow” about me.

I didn’t have the heart to tell him that I have all the pregnancy hormones giving me that glow whether those embryos actually implant or not. No reason to crush his dreams unnecessarily.

Besides, bony knees and laundry aside I don’t see any reason why we can’t be pregnant this time.

We will worry about later, well… later.

 

 

 

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

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

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.

Image by Cliff via Flickr

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

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

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

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

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.

Image

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

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

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

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

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.