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.

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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.

 

Fertilization Report… The Results Are In

We started with 16 eggs…

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Of those 3 were immature so that left…

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Two of those had already degenerated and one was damaged…

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Of the 10 remaining not all of them fertilized so we now have…

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Seven. Seven embryos that will be monitored by time lapse photography tonight and any of those that develop normally will be available to be transferred tomorrow at 9:30 AM.

I have mixed feelings right now. Truthfully, I am deeply saddened that we have only 7 embryos out of 16 eggs. We had 11 embryos when we did genetic testing and only three were normal. So if we have the same percentage of normals that means we may have only one or two normal embryos in this batch. 1.89 embryos to be exact, but it could be less or more.

Still, we have embryos. Many women my age do not have so many. Plus nothing good can come from being down about this. I have to get my mind and body in a state where it is ready to accept and grow an embryo into a beautiful baby.

So there you go. Mixed feelings.

Praying hard and trying to keep a positive mental attitude…

 

Sweet Sixteen

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

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

Let the waiting commence!

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

 

 

 

Nesting

Image by Kenneth Spencer via Flickr

Image by Kenneth Spencer via Flickr

I do it every cycle whether its IVF or FET… Every. Single. Cycle.

In the final days leading up to our procedures I start cleaning and organizing. And when I am done, I clean and organize some more.

Pregnant women nest in order to prepare the home for baby. I suppose it also helps relieve anxiety about the impending birth, the pain, the joy, and changes it will bring to the household. I really wouldn’t know thanks to several weeks of prescribed bed rest when I was pregnant with Spork. But I know a lot about nesting before IVF. I even know why I do it, however having that knowledge doesn’t save me from practicing my own personal brand of crazy.

I nest before IVF in order to gain control over my environment as things begin to feel more and more out of control. I clean in an attempt to occupy my mind, however I try to convince myself and others that I do it to prepare the world around me for 12 days of light activity and waiting.

This time, I took it to a whole new level. My bags are packed, every single linen and piece of clothing in the house is washed and put away, the bills are paid, the drugs I will use this week are neatly organized into a pill box, those drugs that I no longer use are tidied up and stored for a possible later time that I pray never comes. I even boxed up Spork’s 24 month duds and broke out her hand-me-down 2T sizes, washing them and tucking them away (sigh).

This is what I do and I do it so very well.

My nesting began three weeks ago when I began meal planning so I could eliminate stress during the cycle by ensuring that I always had gluten free leftovers to carry with me throughout the state of Michigan as I traveled to and fro for work. Never mind that I never cook anyway and I would have been just fine leaving dinner up to Bill like I always do.

Tonight my nesting ends with an impeccably clean attic. That’s right, attic. I won’t even see my attic over the next 2 weeks while I wait to find out it we are going to have another baby, but I would know it was a flippin’ mess and that would be enough to make me crazy. Not only does this cleaning save me from being even more nuts than I will be during the two week wait,  it helps make me sane in the short term.

Cleaning the attic stops me from obsessing over questions like:

What if there are no eggs in my follicles?

What if we overstimulated and the eggs are immature?

What if Spork permanently damaged Bill’s little swimmers when she jumped on his lap a few days ago?

What if the eggs don’t fertilize?

What if I spill the only HCG within 3 hours of us tonight when I trigger?

The list goes on and on.

If you have followed my blog for more than 5 minutes you have already correctly diagnosed me as a control freak. I could try to fight it but after 38 years I know its pointless. All I can do is recognize it and try to be balanced by not letting my desire to relieve stress create more stress than it relieves. The meal planning failed that test, plus my cooking was pretty bad, which is why I stopped it last week. However it was sort of fun to watch Bill pretend to like my food so I may bring it back for some comic relief during the two week wait.

In fact, I think I will. After all, I can’t control whether or not my embryos attach and grow into healthy babies, but I can make a terrible batch of gluten free swedish meatballs to enjoy eat while we are waiting to find out the results.

Besides, other than a few bland meals, what’s the downside? My attic as well as my soul are better for this.

 

Do any of you do this as well or am I alone in my infertility induced obsessive compulsive behavior?

 

Ultrasound Number 4- Day 11 of Stimulation

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

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

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

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

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

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

Saturday will be the big day!

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

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

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Image by Ben Harrison via Flickr

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

Gosh let’s hope so.

Mama needs a new pair of (baby) shoes!

 

Ultrasound Number 3- Day 9 of Stimulation

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

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

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

Why?

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

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

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

I bet I outlasted them all.

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

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

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

Cue major freak out and sleepless night.

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

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

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

Everything was perfectly normal and exactly as it should be.

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

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

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

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

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

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

 

 

Ouch…

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

Nobody said it would be easy.

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

What happened?

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

Image by Victor Valore via Flickr

Image by Victor Valore via Flickr

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

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

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

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

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

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

Fingers crossed that we are still a go for transfer.

I simply cannot wait until tomorrow.