April 2016 - IVF #3, All clear for phase 1!

This morning, I went in for my second set of baseline tests.  The ultrasound clearly showed that the 18mm follicle had been ovulated, and the other two had shrunk slightly.  Sharon said we would still need to wait on the blood test results to be sure the estrogen levels had gone down before we got the "all clear" to move forward.

Around 2:30pm, I got word from Sharon that my blood tests were good and they are ready for me to start birth control tonight!  She said I should take 2 pills / day for 11 days, then come back in on May 10 for another set of baseline tests before starting the shots.  This is a little different than round #1, since I'll be taking 2 pills / day instead of 1, but he thought a shorter and more intense suppression period would be ideal this time.

I'm glad this puts us back on track for the round #3 schedule, despite the little delay in the birth control phase this week.  Feeling pretty good about it so far!  Particularly because we could see several antral follicles on both ovaries, which will hopefully come into play once we start shots!

April 2016 - IVF #3, Prescriptions & Insurance

On Tuesday, despite the uncooperative follicles, the office decided to go ahead and call in my round #3 medications to the pharmacy.  Well, pharmacies, actually, as this time there will be two separate sources.  Conception Pharmacy will provide the Ovidrel, Menopur and Follistim, while Freedom Pharmacy will provide the Lupron, which it seems Conception does not carry.

Wednesday I got a call from the senior nurse, Rachel.  Conception Pharmacy checked, and my insurance doesn't cover the Follistim, but it does cover the Gonal-F.  She had spoken with my doctor, and while he had wanted to try the Follistim to try something different, he was ok for me to use the Gonal-F instead, since, if you recall "they are like Dr. Pepper vs. Coke" of follicle stimulating hormones (FSH).

I called Conception Pharmacy. How bad could the cost difference be?  Was it worth it?

Candace answered, and Candace told me this:

me:  "Hi Candace!  My name is Kelly Canning.  I hear you all have a prescription for me, but that part of it is not covered by my insurance."

Candace:  "Hi Kelly.  Yes, it looks like the Follistim isn't covered, but the Gonal-F is.  They are essentially the same, just a difference in brand.  When I saw this yesterday, before I called your nurse, I checked with the head pharmacist...it's the same exact formula."

me:  "Ok.  Good to know.  Just out of curiosity, how much of a cost difference is it for me to pay out of pocket for the Follistim?"

Candace: click, click click. "Hmmm...ok, so the Gonal-F is nearly fully covered, only a $150 copay.  We also have a discount coupon with the manufacturer, so it will actually cost you nothing."

me:  "Nothing?  Wow!"

Candace:  "Yep.  Let's see, for the Follistim..." type, type, click, click. "That would be $3,600 out of pocket."

me:  "Holy crap."

Candace:  "Yep."

me:  "I know this sounds like an obvious decision, but let me call you back."

I texted Michael the issue, and then called Rachel back.  I needed to hear from her directly, not just over voicemail, that the desire to try something different and it's potential positive effect wasn't worth the $3,600.  She said it was absolutely not worth that amount to try it.

I called Candace back and ordered the Gonal-F, Menopur, and Ovidrel today.  Freedom Pharmacy will ship the Lupron.  The protocol is still new / different, and the Lupron is thankfully going to work out.

Moral of the story.  Insurance is great to have and it's rare to receive infertility coverage at all.  What it does and doesn't cover can be unpredictable.  Sometimes you've gotta roll with the changes and hope for the best.  If we have to go to rounds #4, #5, etc...we might need that $3,600!

Round #3 meds are now ordered and should arrive via FedEx this Saturday and next Saturday!

April 2016 - Not Quite Yet & Egg vs. Follicle?

Tuesday's baseline check had an unexpected twist.  The ultrasound, which should have shown nothing, or at most a couple very, very small antral follicles, showed 3 fairly sizable follicles.

Yes, you read that right.  I managed to grow more follicles after being off the medicine than while I was on it, and at the time we want no follicles, I have 3.  My ovaries just continue to not cooperate with the process.

For those who might have questions.  The egg is to the follicle as a seed is to fruit...kinda.  Here's a cartoon that might help:

This shows the ovary with various stages of the egg as it starts from being a primordial follicle (I have also heard this called "granulosa"), developing within a fully formed follicle, and then being released during ovulation.

The follicles measured 6mm, 10mm, and 18mm.  Unfortunately, none of these are worthwhile to perform another retrieval...I asked. Twice, just to be sure.  Each one of these little guys feels so valuable.  They said that these likely aren't fully developed and my other hormone levels in the blood test were not ideal for proper egg development within the follicles.  They just need to be out of the way.

You can also read more online.  This site has a pretty clear and short explanation, but is also a little dry.

So here's a little insanity for you.  Now we are getting rid of these unwanted follicles, after so desperately wanting follicles and not getting them in round #2, so we can move on to the wanted ones in round #3.  Ironic, right?

How do we get rid of them?  Well, Sharon (my nurse) handed me a trigger shot to take home and administer that would force me to ovulate 36 hours later.  Sound familiar?  Indeed.  This is the same trigger shot I took before the retrievals.  Ovidrel is the brand name they gave me, but the active drug is actually hCG (human chorionic gonadotropin), which is the same hormone a woman's body produces during pregnancy to support growth of the baby.  It is actually the hormone that if detected in home pregnancy tests and blood tests that confirm pregnancy.  It is also the same hormone that some athletes have used as a performance enhancing drug.  I guess I will have to put off qualifying for the Olympics this year.  

Sharon said that there is a small chance that the egg from the 18mm follicle might be good.  Still not good enough for us to go retrieve, but if we wanted to time intercourse around the 36-40hr mark, we certainly could roll the dice.  Before you get too excited, we decided against it.  While it would be great to skip round #3 and get pregnant, the cons are as follows:

• We would have to wait 2 weeks without medicines to take a pregnancy test
• If we were to get pregnant, given my history / situation is high risk for another miscarriage
• First, another miscarriage would really emotionally suck; as hard as the failed IVF rounds were, miscarriage is far worse
• Also, a miscarriage would put us several months down the road before we could try IVF again
• If we were lucky and got pregnant and had a healthy baby, it would be wonderful, but this would likely eliminate our chances for a second child, since my ovaries would likely be toast after a year or so has passed

So, while the idea was exciting, we decided to stick with the round #3 plan.  After taking the trigger shot Tuesday evening, I likely ovulated this morning about the time I was getting ready for work.  Anticlimactic, I know.

I go back to the RE's office tomorrow morning for another blood test and ultrasound to confirm that at least the biggest follicle has gone away.  The smaller ones, if not gone, will likely be able to be shrunk back down by the birth control pills, which hopefully they will give me permission to start tomorrow afternoon.

April 2016 - IVF #3, The Plan

Last Thursday, we met with the RE.  He was very positive about our options.  Disappointed in the androgen priming protocol, he wants to move on from that this time, and try something different.  Sometimes, he says, it's just about finding the right cocktail of medicines that will convince my ovaries to respond.  Now that we're on to round #3, it does start to feel like one big science experiment, and I'm the principle lab rat.

The options he mentioned were:

• Option 1: Go back to something similar to the first protocol
• Birth control (~2 weeks), less time than in round #1
• Gonal-F and Menopur combo
• Cetrotide antagonist
• Switch to double trigger shot
• Option 2: Change to "Lupron Flare" protocol
• Birth control to start (~2 weeks)
• Start shots with Lupron - used instead of Cetrotide to prevent ovulation too early
• Helps stimulate naturally produced Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) from my own pituitary gland at the beginning of the cycle to hopefully promote more follicles to grow
• If you recall, FSH and LH are the two hormones in the injectable medicines, so this would make use of my own levels of these hormones in addition to the shots
• Swap in Follistim - used instead of Gonal-F
• He said this is just a brand difference "like Dr. Pepper instead of Coke" LoL!
• Stick with Menopur
• Option 3: What I'm calling "Low & Slow"
• We may have to recognize that we just aren't going to get that many follicles
• Perhaps the high-dosage route is hurting instead of helping
• Apply low-dosage for longer time to see if we can do better than previous cycles and focus on quality vs. quantity
• Add-on consideration: Add estrogen priming (no testosterone)
• Pro: Lower level of ovarian supression (bringing the system to a baseline level) at the beginning of the cycle than birth control, which will supress more.
• Con: Like the androgen priming, this takes a whole month of priming before even shots vs. ~2 weeks of birth control
• He said this was 6 vs. half-doz, so we said we would prefer the birth control if this doesn't make a substantive difference.

After a good amount of debate and discussion, he said he would really like to see us try Option 2, the Lupron protocol starting with birth control instead of the estrogen priming.  

Lupron protocols are pretty standard, actually.  They are used widely and often work quite well from what I have read previously.  Our RE on average has better success with Cetrotide, but he said that for some people, Lupron may actually work better.  I will learn more about it as we go, but I believe he called it a "microdose Lupron" protocol, which can be beneficial to low ovarian reserve cases like me.  For an example, I found this link to a typical microdose Lupron flare calendar of treatment (from another clinic, so mine might be different).  If mine is similar, this might mean shots two times a day!  Fun stuff!  Ultimately, it should help to stimulate my body's natural FSH  and LH and hopefully produce more follicles than round #2.  Sounds like a great option to try.  Using a different approach feels good, and gives us some hope.

Additionally, I'm glad he agreed to the birth control start, which is a lot shorter than the priming.  Emotionally, it was pretty difficult to have round #2 fail after working on it for 6 weeks.  Even though the shots portion was relatively short.

I'm actually getting used to the shots.  Glad to mix in the Follistim instead of just the straight Menopur, which stings and burns badly when injected alone and in high dosage.  Not sure how doing the Lupron shots twice daily will work, if that's indeed how they set me up.  With work, it might be tough to figure out how to do the morning dose.  I may have to keep it in the office fridge and do it in the bathroom...  Interested to see what Sharon (my nurse) gives me for instructions.

The one thing he said that has haunted me a little since Thursday was, "If this cycle doesn't work, we will need to regroup and discuss other options."  He said this gently and quickly talked about how he was optimistic about this protocol, but I am afraid already I know what this means.  If my eggs are both low quantity and quality and we can't get enough to be successful in getting pregnant at all, we have to consider eliminating my eggs as part of the equation vs. continuing on and on with protocols that won't likely work.  This means considering donor eggs, embryo adoption (if it is important to me to experience pregnancy), or just old-fashioned adoption.  Just the thought of this is a little soul-crushing.  It's admitting defeat for me, at least in some way.  It means that even if I do have a child, he or she won't be biologically mine.  While whatever children we raise would be 100% ours and loved 100% as much, they wouldn't have my eyes, or my curls, or my laugh...  

A million thoughts are rushing through my head on this.  Last night, the weight of it all got to me.  Tuesday is my baseline appointment before the birth control starts.  Here we go again, but with heavier implications if we fail.  I went from wanting to kick IVF ass last week to feeling a huge amount of despair.  I cried myself to sleep with Michael holding me and telling me it would all be ok.  I woke up at 2:30am and couldn't get back to sleep because my brain was really focusing in on the pressure of this round working well and what it means if it doesn't.  How many more rounds will they let us try before saying that there's little to no hope?  Is this it?  The next thing I knew, my alarm went off at 5:30am.  Sigh.

I know I'm getting carried away, but if you've read this blog from the start, you'll know that rational thinking doesn't always win out in this process!  My focus needs to be on this cycle and on being as positive as I can be for the current step to work.  As Michael said last night, "It might work out great and then all of that anxiety and despair would be suffered needlessly."  I will likely need to be reminded of that when I'm ears deep in hormones here in a couple of weeks.

Next step:  I will see my RE for baseline tests tomorrow, and maybe ask him a couple more questions on the protocol and maybe what "regroup" means...

April 2016 - IVF #2, Results

Last night was the worst storm Houston has seen in a while.  After midnight the light show began, and it was like there was a disco strobe punctuated with house-rattling thunder until well after the sun was up.  Between midnight and 5:00am our neighborhood received somewhere around 11 inches of rain.  This was the case for the vast majority of the greater Houston area.

Around 4:00am, our power went out and the generator didn't come on right away.  We checked the fuse box, just in case, and unplugged some thing that might be expensive to replace if there was a surge.  In 2008 in our previous home in Atascocita, lightening struck our lot and surged through our home via the cable wire that was buried near the strike.  It melted every window and door security monitor switch as well as ruining inputs on many of our electronics.  Pretty much anything connected to the cable or internet.  Not much fun, but at least the house didn't catch fire.

There were already reports of flooding and blocked roads at 4:00am.  Our power came back one fairly quickly, but the internet didn't for about 4 more hours.  By 6:00am, it was deemed not safe to be out and we were told by our managers to stay home and work from there.

As we checked the radar via phone signal, we had came to the realization that we may not get the call today either.  While that was frustrating, I couldn't help but think how worse it would be if today was my retrieval day.  It certainly was for some ladies out there who triggered ~34 hours ago.  Right now with their significant others, they are desperately trying to navigate to the clinic via whatever circuitous route or mode (maybe kayak or speed boat?) that might get there before ovulation takes place and the whole thing is ruined.  That would be awful.  Waiting for my news isn't that bad in comparison.  Thinking about this, made me so glad my retrieval was last Monday.

Around 10:00am, the internet returned and the rain continued.  I broke down and sent a portal message to Michelle, first wishing her well and hoping she was safe from the weather, and next asking if there's an update on our embryo.  About an hour later I left her a similar voicemail.  After that call, I committed to that being all I do to reach out to them today.  If they were short staffed or dealing with critical appointments only, I didn't want to be the non-critical one demanding their attention.

For lunch we sat together and nibbled leftovers.  I was allowed a short break from the No-Fun Diet since the retrieval, so we shared half of my leftover cheeseburger and some fried okra.  Other indulgences during this time have included: my chocolate milk shake post-retrieval, a couple caffeinated coffees, a delicious grilled cheese and tomato soup, some pizza, and the other half of that cheeseburger.  All gluten with dairy on top.  All supremely delicious.  Tomorrow, I'm getting back on the NFD wagon.  Partly because my gut is, not surprisingly, protesting the splurge...and partly because, if my cycle restarts this week, we will move toward round #3 and it's time to recommit.

Dear Cheese,
I will miss you in all of your forms.  You are my favorite, but please don't tell Gluten...I like Gluten a lot, too, but there is no passable substitute for precious cheese.  I hope you two are ok sharing my affections both now and forevermore.  I do not know when next we next shall meet, but I look forward to it with all my heart.

Love and kisses,
Kelly

Around 2:30pm, it's still raining and Michael stepped into the other room for a conference call.  At 2:35pm, my phone rang and I jumped out of my skin.  It was Michelle!  I asked if she was keeping dry and safe, and she said she was also working from home today.  Her internet had been down most of the morning, which is why she was calling so late.  She hesitated slightly before gently telling me that she was calling with bad news.  Our embryo's development degraded, and in the end, it didn't make it to the final stage.  It was discarded.  I told her thank you for the news, and I hoped she and I would get to speak again during the next cycle.  It must be fairly awful to do that job of breaking such harsh news to couples all day every day.

Failure.  I walked down the hall to the office, and as I came in, Michael could see it on my face.  Thank God, I didn't have to say it.  He muted the phone, stood and just hugged me.  I fell apart a little.  I cried in his arms for several minutes and he stroked my hair and said, "It will be ok."  I kept saying, "I'm so sorry!", which I know I shouldn't, and to which he holds me tighter and says, "Don't say that.  It's not your fault!".  But it's how I feel in these moments, being the one with the broken ovaries and scrambled eggs.  It really Isn't Very Fair...

I had been so hopeful for this little egg from the time we knew it was likely just the one.  Yes, the odds were long from that point onward.  We both knew this.  As the results of "0 blasts" sunk in, the ache and disappointment was slightly more tolerable than cycle #1 of going from 5 to 1, and I think I know why.  This round was different because the option had become either quit (cancel the cycle and abandon the follicles) or give our singleton a fighting chance.  For me, I didn't know if that egg in that follicle might become our baby, and that was enough for me not to quit.  We gave it every chance, and it still failed.  Frustrating as hell that we are back to the same spot we were in early February, but we tried, and this one just wasn't our baby.

We needed to know, and now we do.  It's not the outcome we might have hoped for.  Damn, I would have loved to have another blastocyst on ice and take that baby step forward!  I wanted so much for some measurable progress from the investment of these 6 weeks!  That would have been sweet and firm affirmation to the choice to retrieve anyway, even with one (and a half?) follicle(s).  Now we are numerically no further along than we were in early February...and it's getting to be late April.

We still feel we did the right thing.  If I am put in this situation again, I believe I would chose the same path, as hard as it was today, taking that phone call while wearing my optimistic egg socks, and dealing with the finality and 0 progress of round #2.  At least we are safe and warm in our undamaged home.  The rest of the city is in an officially declared disaster from this weather.  We will certainly be ok.  It's only crappy news.  One step forward, one back.

I scheduled an appointment with my RE for Thursday afternoon to talk strategy.  If we are lucky, my cycle will have started and they can also take baselines (blood tests and ultrasound) for round #3.  We are ready to try again, and hopefully this time we can kick infertility's ass...or at least make some measurable progress.

April 2016 - IVF #2, Day 6 Report(less)

It's 6:30pm and Michelle hasn't yet called.  I'm beginning to think that "tomorrow" really meant "Monday", or something else has intervened and prevented her from calling.  I'm still a little hormone crazy, but it was on speaker phone, and when she said, "Tomorrow", I asked, "Really? Tomorrow?" and she said, "Yes."  Michael is my witness...

Sigh...  So unless she calls this evening by, say, 9-ish(?), I think we will have to wait until tomorrow to hear the verdict.

I've been moderately anxious today, and never strayed too far from my phone.  Every so often, I'll check to be sure I don't have any missed calls or voicemail that might have sneeked by me in the last, I don't know, 10 minutes.

I passed the time reading two books.  One recommended by an IVF friend late last week (Thanks, Erica!!) entitled Every Drunken Cheerleader: Why Not Me? by Kristine Waits.  A really humorous, and somewhat spiritual perspective on enduring and surviving infertility.  It is a great read not only for the person / couple going through it all, but for those who support them.  Lots of great chapters on what it's like, what to say that helps, and shows through her own experience how the roller-coaster of emotions and sanity is REAL, people!  I laughed.  I cried.  It was really worth the read.  A copy is en route to my mother's house and will arrive tomorrow!  Quote that sticks out most to me today: "...sometimes God narrows your chances to prove to you that He is the one winning."  Praying that's true...

My next read is focused entirely on the lighthearted side of infertility, written by a stand-up comedian named Lori Shandle-Fox.  It's called Lauging is Conceivable, and so far I'm only on the first chapter, "Loss of Mind: The Only Guaranteed Side Effect", and it's fantastic.  This woman is hilarious.  In all my posts, "IVF" now stands for "Isn't Very Fair"...just for future reference.

Both of these are short, and not terribly heavy, which is perfect for me and possibly for the interested observer.  I need to see the lighter side and laugh about as much of it as I can.

Ok.  7:07pm.  Still no call.  I will update later if it comes...otherwise, I guess we will find out tomorrow!  Argh...

Just for Fun

While enduring the waiting phase, I found and ordered these as inspiration for what's left of this cycle and for round #3.  They came in the mail today!

Egg socks!!!

April 2016 - IVF #2, Day 5 Report

My RE called Friday evening to check in.  He asked how we were holding up, and I told him we were alright, but had heard that our embryo was a little slow to develop as of Thurday's Day 3 report.  I asked him what he thinks of that result.  He said that slow developing embryos come along here and there, and while it's not a great sign and could be indicative of a low-quality egg, we shouldn't count it out.  He said that the report is just a snapshot in time as of Thursday morning, and by Thursday afternoon it could have split to 6-8 cells, we just don't know and that's why they like to let them grow longer.  As long as the embryo keeps moving forward, that's a good sign, but this could mean that our Day 5 report on Saturday might be just an update, not a final report.  If it's slow now, it might just take a little longer to get from morula stage to blastocyst stage.

Saturday, Michelle called at 3:05pm. I put her on speaker phone so we could both listen, and we held our breath.  The embryo is still growing, she said, but it is still proceeding slowly and they want to give it another day to see if it will reach the final stage of becoming a blastocyst.  It's stage is currently listed as "other", she continued, which isn't very descriptive, but means it is between stages of development. She said she would call tomorrow with the outcome of the extra waiting.

Hanging up, I cried a little as the relief spread through my chest.  We are still moving forward and still have some hope.  "I'm so happy it isn't over yet," is all I could say to Michael to explain how I was feeling.  My face tingled a little, but that wasn't the phone call adrenaline.  It was the facial I got at the spa earlier today in the hopes of staving off the onslaught of pimples that I got during the last cycle around Day 5/6.

I'm not a regular spa person, but I do enjoy it when I go.  I actually haven't gotten a formal (i.e. at the nail salon, non-do-it-yourself type) pedicure since before my brother's wedding in September.  After 10 months of pharma-grade hormone meds interrupted by 9 weeks of pregnancy hormones, I can't stress enough the value of some pampering to help make a person feel somewhat normal again.  After my miscarriage, I got a rather drastic haircut (~8" off!).  In the last couple of months (including today) I have done two pore-vacuuming, dead-skin-dissolving hydrofacials that have made me feel refreshed and human again.  I should have started this routine sooner.  The fluctuations of hormone levels endured during these treatments are fairly intense.  I can honestly say that haven't felt like my real, authentic self in months.  I have been saving up some gift certificates for massages since Christmas, and I'm thinking before round #3 would be an excellent time to cash in one of those.

If you know someone going through infertility and you are looking for something you can do to help, a gift or outing together full of relaxation or refreshment may be a nice way to say you care.  This is not a hint, I'm not asking for anything...I'm very well taken care of with my facials and massage coupons.  I'm making a suggestion for others, particularly those enduring the worst part of this whole process, which may very well be the waiting part.  This round, I weighed briefly which phase is tougher:  the injections or the waiting.  With the injections, I feel like we are at least taking a daily and physical action toward a baby, even with the headaches, the tenderness and bloating...with the waiting, there is nothing we can do but sit here, think about the odds and possible outcomes, and allow my Jr. High School complexion to make a full-force comeback.  The waiting is harder, and I'm sure it will be worse when we hopefully move to transfer and are waiting to take a pregnancy test.  Some form of detox / relaxation / restorative treatment is a very nice way to pass the time.

The facial I had today, I scheduled it on a whim, and it turned out to be booked for the same time-frame that Michelle said she would call.  I actually left my phone with Michael and took my work phone with me instead, just in case she called while I was in the treatment room.  I called him just before and after to check if the call had come or not...neurotic?  Me?  Noooo!  As you might have noticed, I got home in time for us to take the call together, which was great, but wouldn't have been the end of the world if I hadn't.  Today, taking a break from it was more important than knowing right away.

Now we get to hold our breath and maintain our cautious optimism until tomorrow!

April 2016 - IVF #2, Day 3 Report

For the record, yesterday was my weekly, acupuncture appointment, and my new daily pill count is up to 27 (a new record!).  She added back in the herbal detox pills until we start the next cycle.  Yay pills!

Now it's Thursday morning and I'm waiting for Michelle to call.  The last couple of days, I have felt exhausted, but this morning, I'm very much awake and alert.  I had some meetings and phone calls to start of the morning, which were great to keep me busy and distracted, but now it's 10:30am, and I probably won't hear from her for another hour.

As we learned during round 1, typical healthy day 3 embryos are in the ~8 cell range.  On Day 3 of round 1, we had 5 embryos ranging from 4 cells to 10 cells.  Michelle told me then that the 4 cell was concerning, but that there have been cases of 4 cell embryos on Day 3 still making it to Day 5.  For us, only the 10 cell embryo made it all the way to day 5 as a blastocyst of >100 cells.

At after Day 5 of round 1, our RE explained that their lab excels at fostering embryos from Day 3-5...they have worked hard to perfect the conditions and culture to allow healthy embryos to succeed.  This means that the 4 growing embryos that didn't make it were likely genetically abnormal.  They wouldn't have made healthy babies, so at some point, nature intervenes, and they just stop developing.

Progression of embryos from Day 1-5.

I'm feeling nervous.  I know that this egg was either normal or abnormal from the very beginning...there is no way for the embryologist to tell if a normal-looking mature egg has all the right chromosomes.  They just fertilize it and we all wait.  Although the sample size was small, round 1 would indicate that only 1 of 7 of my eggs might be healthy.  My RE would tell me not to use this small sample in this way, but it's what I'm thinking about now, as I wait for Michelle to call.

Monday's report was relatively binary...2 eggs, either they fertilized or they didn't.  We got a yes for one and a no for the other.  Simple.  And I was so thankful that we didn't lose them both in the first 24 hours after the procedure, which would have been a very abrupt end to the nearly 6 weeks of preparation.

Today, there's potentially more information to be had.  The embryo could have died in the last 48 hours, in which case we are done and we shift all our focus to the next round.  If it's still growing, the cell count can give us an indication of how well it's growing, although not definitively.

This whole fertility process feels like living data point to data point, just hoping that the next breadcrumb of information is good...that it's not over yet, and you can hope just a little bit longer.  What else can we learn today?  What does that tell us?  How much can we trust this information to reflect reality?  When can we know the next thing?  What will we do differently from there...?  It's like we are feeling our way through this dark forest.  We are being led through it by a specialist who knows much more about the damn forest than we do, but can't see much further down the path to be able to say if there is an end in sight.

I know that we need to have faith that it will all work out, and that there will be a baby at the end of the path, no matter how long the path ends up being.  Easier said than done...  While Michael has been great at this, quite frankly, I sucked at it for most of February and March as well as various points along the line during the last 2 years.  I felt like sitting down in the middle of the forest in protest.  "This isn't fair!" I wanted to scream, "This works out so easily for so many...why not me?!"  Each time, Michael has helped me get back up, dusted me off, and held my hand tightly as we stumble forward down the path again and the next breadcrumb of data...

12:00pm  Ok, it's noon and she still hasn't called.  I'm guessing I won't hear from her until after lunch.  Sigh...

1:07pm  Our embryo is still growing!!!  Embarrassingly, I gave up and called her...at the same time she was calling me.  I hung up after leaving her a message, and the voicemail appeared.  Doh!  Her message said the embryo is still growing and she would call back on Saturday with the Day 5 results.  Whew!  So thrilled that there's still hope for this round!

I immediately called her back and left a message to apologize for being impatient and missing her call, but also to ask what the cell count of our little embryo is today.  That might give some indication on how strongly it's growing and how optimistic we can be for Saturday's results.

When I heard back from Michelle, it was unfortunately not very promising news.  The embryo was only at 3 cells this morning.  That's less than our smallest one last time.  It's not completely hopeless, but certainly not likely to succeed through Day 5.

April 2016 - IVF #2, Fertilization / Day 1 Report

This morning, I woke up and felt the discomfort had started to fade.  Not likely to need much of the pain medicine today, but I'm still feeling like my body is worn and exhausted.  Michael left early for work, though I could tell he was worried to leave me on my own.  I assured him I'm fine to be on my own.  A day of rest in pjs at home is just what I need.

Waiting for the "Day 1" call is a little tough.  What should I prepare for?  There are only a few options this time...given we are only starting with 2 eggs (vs. 7 last time).  If they both fertilize that would be AMAZING!  But what if neither of them do?  Then, within 24 hrs of the procedure, we would be back to where we were at the beginning of February.

Before getting too deep in this Day 1 business, here's a recap of how the process works after the retrieval:

• Eggs retrieved
• Sperm sample given
• Embryologist examines eggs and evaluates egg maturity
• Embryo lab washes sperm and picks the shiniest, healthiest one(s) to inject into the egg(s) using ICSI (intracytoplasmic sperm injection) process

ICSI Process involves injecting a single sperm into a mature egg.  This increases fertilization success rates vs. simply adding sperm to the petri dish and relying on natural fertilization to take place.

• Fertilized egg(s) are suspended in a culture fluid in a petri dish to grow
• Embryologist checks / reports on embryo(s) after 24 hours to see if they are still growing normally
• This is the call I'm waiting for on Tuesday morning to learn how many fertilized and made it through Day 1
• Subsequent checks / reports occur on Day 3 and Day 5
• On Day 5, if the embryo has formed a 100+ cell healthy blastocyst, the embryologist will take a ~2 cell sample from it, then cryogenically freeze the blastocyst.
• The sample is then frozen and sent off for genetic testing (PGS/PGD), where all 24 chromosome pairs are mapped to confirm that the embryo is normal, greatly reducing the risk of miscarriage or genetic disorder (like down syndrome).  This takes ~2 weeks.

The process is complex, and extends over several days.  At any point, we could end up with nothing, but we knew that when we went forward with the retrieval despite having only 2 little follicles.  I would LOVE for them both to work, but that's probably unrealistic, so that isn't the news I was expecting to hear.  Even if we end up with nothing from this round, I didn't want it to happen today.  I wanted to at least see some encouraging results that might give us some more to learn and hope for the next round.

The phone rang at 11:30am.  Michelle, the lady who communicates the lab reports, tells me we have 1 successfully fertilized and growing embryo!  She will call me back on Thursday with the next update.  When I hung up the phone, tears began rolling down my cheeks.  I was so happy to have some form of good news.  This hasn't been a waste, and there's still a chance.  One hurdle down!  I texted Michael the good news the minute I could pull myself together.  He's thrilled, too.  We know the odds are still slim, but at least we have something to celebrate today!

I'm feeling myself turning an emotional corner...the weariness and despair that have eaten at me during the last couple of months feels like it is starting to fade.  Ending this cycle with 0 would still be hard to handle, but it wouldn't feel like the end of the world.  And for now there's still some hope for our one little growing embryo as well as the one on ice from IVF #1!

April 2016 - IVF #2, Retrieval

Hospital Bracelet, retrieval #2

The retrieval yesterday went well...in fact, it went better than we expected.  Sunday night, I had a little bit of trouble calming my mind to sleep until about 1:00am.  My alarm woke me at 5:00am, and I jumped in the shower.  Around 5:30am, Michael and I got on the road and headed to the Piney Point Surgical Center (~50 min drive from home).  He sweetly remembered to grab my favorite throw blanket on the way out.

From the start, I felt more confident going into it than last time.  For reference, my personal list of nice-to-haves for retrieval procedures:

• Remove all jewelry and just leave it at home
• Bring ID and insurance card
• List of medicines / supplements you are currently taking and when you last took them.
• Warm socks to wear during the procedure...fun design is even better!  
• This is actually the only piece of clothing (other than the hospital gown) that they will let you wear!
• Comfortable clothes which are easy to put back on when you're hazy afterwards
• Personally, I prefer stretchy pants because a) no zippers and buttons, and b) your stomach is crampy / achy afterwards
• Also, I dress warmly (cardigan, sweatshirt, etc), regardless of the temperature outside.  Coming out of anesthesia, I'm usually chilly / shivery.
• Wear shoes that are easy to put back on and walk in when you're woozy.
• Chapstick for before and after since the procedure is a bit dehydrating
• Soft throw blanket in the car for the ride home
• Chocolate milkshake from Whataburger on the way home!
• Oh, and less pleasant, but I have learned the hard way to drink some Miralax from the moment I get home.  
• The combination of drugs they give for anesthesia and pain resulted in some serious blockage after my D&C.  
• Even with the Miralax, it could be several days before you experience...ahem...relief.  Trust me.

The nurse called me back around 6:45am.  The IV went in without incident this time, and I realized I'm starting to find the sting of those needles far too familiar.  Michael came into the prep room after I was changed and IV-ed.  The friendly anesthesiologist came in and we spoke for a bit about the procedure and she confirmed my current meds from my paperwork.  My RE, freshly back from his vacation, came in and we had a nice chat about the procedure and expectations.  He did say that he thinks we were lucky last time with the 7 we were able to grow and retrieve and that this cycle is more likely evidence that I'm coming in line with averages and what he would expect given my situation.  If we are to do another round after this, we will adapt and change the medicines to see if we can improve results.

It was then time to head into the procedure room.  The nurse led me into the room adjacent to the one I was in for my D&C and IVF #1.  Getting onto the table, I felt like a veteran of this process, which was a little funny and frustrating at the same time.  This was procedure #4 (since November) with the same kind of prep and setup.  I spread my arms onto the extended arm platforms as the nurse arranges the stirrups and covers my legs.  The anesthesiologist's assistant introduced herself, covered my face with an oxygen mask, and said I would feel the medicine start going through my IV shortly.  It burns at first as it climbs my arm, then I start to feel it in my chest and head.  For fun, I see how long I can keep my eyes open before it takes over.  I find myself thinking about Michael and his part in all this, which is likely about to begin simultaneously in another room down the hall.

I wake up in recovery with a nice young nurse, who brings me a bottle of apple juice to sip while she removes my IV and stick-on nodes from the monitors.  Once she sees I'm reasonably coherent, she brings Michael back along with my bag of clothes.  We wait for a few minutes until our RE can come give us a debrief.  When he arrived, he told us he got 2 eggs!  TWO EGGS!  Better than we thought!  He says he's not sure about the maturity of the second one, but still, good news.  He walks through the usual routine with us...fertilization will happen that same day and we will hear back from them on Monday with results of that step.  He said, as we already knew, that I would get a period in the next week to 10 days, and to get in touch with the office when that happens.

Michael helped me change back into my clothes, and a nurse helps me into a wheelchair and rolls me out to the parking lot.  Michael wraps me in the fuzzy, warm throw blanket and turns the seat warmer on in the front seat and we head in the direction of home.  Two things (beside the blanket and seat warmer) are making me feel very happy and warm inside: we got TWO eggs when we thought we would only get one, and I'm about to have a big ol' chocolate milkshake on the way home...first dairy I've consumed in WEEKS!  And it was so gooooooood!!

Indeed!

Now, we would just have to wait...if our eggs are mature enough for fertilization and whether they make it through the first day...all of this is out of our control now.  The chances are small, but we are at least giving them a chance.  And 2 > 1, which is an even better chance!

We went home and watched an animated movie (my favorite when coming off of anesthesia) and rested.  I took some pain meds for the discomfort, and anytime I needed to get up, Michael was right there helping me manage the dizziness safely.  Have I told you recently how lucky I am to have married this man?  I probably haven't said it enough...

I had no trouble falling to sleep last night.  The Tylenol 3 helped, but mostly, I just felt calm knowing our parts were finished for now.

All caught up! Still there?

I'm finally caught up on the blog posts!  It feels wonderful to have gotten it all down in one way or another.  I do find myself going back and adding things here and there to the older posts.  Most of them were stream of consciousness writing just to get it all down during a time in March when I was really struggling under the weight of it all, feeling lost in the process, and seeking some kind of outlet for those feelings.

If you're reading this now and have stuck with me from the start, I'm in awe and I thank you.  I hope this blog provides a window into what treating and living with infertility is like and what Michael's and my experience has been so far.  Maybe it will be something we can share with our children one day to help them understand how much they are wanted and loved.

There are all kinds of infertility challenges, and ours is just one of many stories of couples encountering a longer, bumpier path to having children (a little more than 1 in 10 couples struggle with this in some way).  We can't express how essential it has been for us to have a network of friends and family willing to navigate this process, learn with us, and feel our pain, frustration, and hope during this time in our lives.

I do hope it doesn't feel like we are testing the limits of your support or that this is all we can talk about when we are with you.  It's been all-consuming for us, but it doesn't have to be for you...it is completely acceptable and encouraged to change the subject if this is the case!  On the other hand, we don't mind your questions, check-ins, and offers of support.  This is not something that I have ever wanted to us to go through privately or quietly, as many choose to do.  We would much rather you know why we look a bit worn and weathered, especially when we hit some of the rougher patches.  I will be happy to give the latest on my uncooperative ovaries and elusive eggs whenever asked.

For both of us, this has been quite the education in reproductive science and modern medicine, and we are happy to share that with others, when there is interest, especially if it could come in handy for you or someone you may know someday.

We love you dearly.  Thank you for reading!

April 2016 - IVF #2, Long odds

Based on the results of the blood test and discussion with my RE on Friday, they called me in for a Saturday check on April 9, 9am.  They did this, as they did last time, because they were concerned we might be reaching the end of possible stimulation and need to trigger over the weekend.  

April 9 was only day 9 of shots, I was pretty frustrated.  Instead of sleeping, I spent a chunk of my night searching the internet for options in this kind of case, just to be able to ask any other questions the next day.  I read about sacrificing the dominant follicle in order to give the smaller follicles more time.  If the estrogen levels support it, it is possible to keep "stimming" and let the dominant follicle get too big (usually >25mm), making it "post-mature" or over-ripe and likely unusable, meanwhile the smaller follicles have time to grow and catch up.  

Our Saturday check was with the on-call RE.  After catching him up with a brief summary of our situation, he performed the scan and helped answer most of our questions.  He was very good and very willing to discuss options and explain what was happening.  He said that sacrificing was a possibility, depending on my blood test results.  The best thing he said was that he has had patients who ended up with babies (actual babies!) after IVF cycles with one lonely follicle.  He said that for these patients, he had recommended cancelling out of the odds being quite low, but they wanted to go forward anyway...it can work.  

We both figured this was better than quitting.  We left the appointment knowing that the "dominant" follicle (we started calling it the super egg, perhaps with the hope it would be just that), had slowed it's growth, but was very healthy looking and mature.  There was a small ~10mm follicle next to it on the left side, not big enough for retrieval, likely, but showing some catch up.  We had to wait for the blood tests, and my RE would see them and make a decision.  

The nurse on call rung my cell phone by lunch time.  Based on the blood tests, my estrogen levels were slowing down, and it was time to trigger.  We couldn't wait any longer or give the little ones more time.  We had to take 2 Ovidrel trigger shots that night at exactly 8:00:00pm, and my retrieval was scheduled for Monday at 7:15:00am.  Disappointed, I confirmed the information, and hung up.  As optimistic as our attitude toward this one follicle seems so far, the creeping doubt was eating away at the corners of that optimism.  Could all this have been for nothing?  There is so much that can go wrong at each step, leaving us with nothing from this cycle...

• During retrieval, they might not even find an egg in there.
• If they retrieve an egg, it might not be healthy / mature.
• We lost 1 of 7 at this stage during IVF #1.
• If it is mature, it might not fertilize.
• If it fertilizes, it might not make it through day 1.
• We lost 1 of 7 at this stage during IVF #1.
• If it makes it through day 1, it might not make it to day 3.
• If it makes it through day 3, it might not make it to day 5 to be sampled and frozen .
• We lost 4 of 7 at this stage during IVF #1.
• If it makes it to sampling / freezing, we could wait the additional ~2 weeks and find out it isn't genetically normal.
• Recall, we didn't get to know this about our 1 frozen embryo from IVF #1, since they didn't sample it before freezing due to a paperwork error, but we will find out at some point.

The generally accepted statistics for my clinic is that 70% of the eggs retrieved will fertilize, and 50% of those will make it to freeze.  These were long odds if you're starting with 1 single egg.  I suppose there could be a very small chance that the second ~10mm follicle grows and matures just enough by Monday morning to give us 2 eggs, but from what we understand about the basics of follicle / egg development and how it was measuring at Saturday's scan, that would be a surprise.

Stopping now and quitting still didn't feel like an option.  It's possible this could be our baby, and I am not about to give up on that possibility for my own comfort.  The retrieval will put me under anesthesia again, I will be uncomfortable afterwards, Michael has to do his part, and we will both miss a day of work to do it all.  This feels like a reasonable price to pay to give this egg a chance.   

As I write this now, it is Sunday evening before my Monday morning procedure.  We administered the trigger shots last night (Saturday, April 9) at exactly 8:00:00pm.  Thank you cell phone clocks for your accuracy and universality!  I also started my Z-pack (5-day course of antibiotics).

Tonight, we have a reprieve from shots, though yesterday's were nearly undetectable compared to the Menopur injections.  This reprieve is bittersweet, since we would have preferred to be able to keep going a bit longer, but as we have come to learn through this IVF process, we have to find some form of comfort in allowing it to be out of our hands.  

With injections phase finished, here's a shot (hehehe!) of all the injection medicines I took this cycle:

All the vials from cycle #2.  Each row = 1 day of medicine.
Bottom row is the 2x Ovidrel trigger shots, which come pre-loaded with meds.

On to the next phase of retrieval (tomorrow) and then (if we are lucky and get a good egg) on to the waiting phase again!  Right now on Sunday evening, the best way I can describe my state of mind is that I feel like I'm getting my game face on for tomorrow.  I feel more positive about tomorrow than I did last time, even with fewer follicles than in round #1.  Not sure why exactly.  Perhaps some of it is because I know what to expect from the procedure, but I think the calm extends beyond that somehow.  Regardless of tomorrow's results, I do feel like a 3rd cycle is now a reality, so it could be that I see the retrieval tomorrow (successful or not) as just one step down a longer road.  Maybe I just have faith in my one little follicle...  Regardless of why, it feels good to find a little calm.

Listening to "Break My Heart Sweetly" this evening, which has become a favorite of ours during the last few months.  Another that really hit home for me has been "Just Be Held"...thank you, Regan.

April 2016 - IVF #2, Let the shots begin...

At the new dosage (600 IU Menopur), I had just enough left over from the last cycle to cover 1 day of medicine.  The nurse had already put in the new prescription for the "stims" earler that week, and I had placed the order the day before.  They would be delivered Friday morning via FedEx.  This time, I took photos of what I received:

IVF #2 meds delivery via FedEx

Opening the box

All the fixin's

The box came with:

• 88 vials of Menopur
• 6 Cetrotide doses
• 2 Ovidrel shots (aka "trigger" shots)
• 2 Z-packs (His and Hers)
• Syringes
• Mixing caps
• Injection needles
• Sharps disposal container
• Ice packs to keep it all cold, which are great for road trips...
• And the receipts!

It's an IVF kit in a box.  11 days of Menopur, plus my 1 day of leftover Menopur from last time gives me 12 days.  If we have to continue beyond 12 days, I can call the pharmacy, order the extras I need, which will get delivered overnight.  My insurance coverage on this medicine is very good.  For the first round, which lasted 15 days + trigger day, my meds cost me about $1,200 vs. a full price cost of nearly $10,000.  This batch of 11 days cost $380.  Refills / extras get quite a bit more expensive, but we are still very fortunate to have the coverage we have!

Shots started officially on Friday, April 1.  600 iu of Menopur takes quite a bit longer to mix.  I'm using more saline than before ~1.5cc across 8 vials of the soluable powder pills.  The main difference this time isn't in the mixing...with the higher concentration of Menopur and volume of shot, the injection stings / burns badly and continues to burn for about 10 mins after being injected.  Even with the ice.  Curious if it would be better without the ice, we tried it in the hope that the easier flow of the fluid into the tissue might improve or at least reduce the duration of the burn.  No luck...worse.

Poor Michael was the one giving them to me, hearing me utter "Son of a BITCH!" on more than one occasion.  I tried not to show him how much it hurt (at least while he was doing it), because it was pretty hard on him to do something that hurt me like that everyday.  Well, we've made it this far.  I can grit my teeth through a couple weeks of these...it will be worth it.  Eyes on the prize!

Here's what my evening's standard supplies look like:

Menopur shot supplies (powder vials x8, saline vial x1, alcohol pads x2, syringe x1, injection needle x1, mixing cap x1).  Does not include Cetrotide shot.

Menopur vial up close.  Powder is visible as a disc / pill, which dissolves upon contact with the saline.  Each of these must be filled, swirled to mix, then drained in sequence to make the final formulation for each night's injection.

Frozen gel pack, new for cycle #2.  Thank you, Ryan Mathes!

My ultrasounds and blood test checks were scheduled for Monday, Wednesday, Friday starting on the morning of the 4th day of shots, which I was to take every evening.  The first couple of appointments didn't show much, save for the cyst we already knew about on the right ovary.  The second appointment did show one follicle on the left side starting out pretty strong.  This would ultimately turn out as what they call a "dominant" follicle.  While a few smaller follicles would show up by the weekend of April 9, this "dominant" follicle was the only one that would grow strongly during this cycle.  

After the second check appointment, my nurse called me.  She said she discussed the results with my RE, and he wanted to prepare me for potentially canceling the cycle if there isn't reasonable improvement by the next check on Friday.  This would mean stopping the shots alltogether and giving up for this round.  

I was a little stunned.  It had been 5 weeks of prep at that point (including all the androgen priming and associated nausea), but it felt like we just started the shots phase.  It hadn't even been a week of shots yet..last time we went 15 days.  Can't we give them more time?  I wasn't even considering the possibility of cancellation for this round.  We were doing "everything and the kitchen sink" protocol.  In my thought process up to this moment, it had been more about how many we would get in the end, not whether or not we would get to the end.  Damn, this was bad news.  She said to stay positive and Friday we might catch up...

I got in the car and drove to my acupuncture appointment right after the call with the nurse.  I asked Jaime to give me everything she thought would help.  She added some more needles, hooked me up to the stim machine, and increased my pill count to 20/day.  For the first time since my first week of treatments, I couldn't clear my head enough to fall asleep during the treatment.

On Friday, April 8, we both went into my check appointment with the nurse only (the RE was out of town).  As she performed the ultrasound, it was obvious things hadn't improved.  The small ones were still small, and the big "dominant" one was still growing ~15mm avg diameter.  We started to discuss feelings about "to cancel or not to cancel".  After all we have been through, including the 5 most recent weeks of prep, and what we know about my low reserve of eggs, every single one feels valuable.  Even the little ~5mm ones feel valuable, if we can afford to give them more time.  Assuming there is no considerable risk or potential delay to the next cycle (as it was becoming obvious we would need), we were both on board for doing a retrieval, even if it was just for 1 follicle.  If the RE was game, we were too.  This could be a very healthy and wonderful egg, and it would be such a shame to waste it.  And if we could get through a few more days of shots, perhaps it could be more than 1...

February/March/April 2016 - IVF #2, Androgen Priming

The break we took from (most of) it in February was nice.  I had a couple weeks of business trips and a baby shower to throw for a friend.  February was busy enough without all the shots and doctor visits.  I needed the time to get my attitude in the right place for starting over again.  I did continue with the acupuncture, natural supplements, and fun-free diet...figured it was easier to keep it going than go back and forth, and hopefully help more along the way.

February was the month of the most pills I have ever consumed.  From the time of my retrieval to the time I started the next phase in March, I was taking 25 pills / day as directed by my RE and acupuncturist.  Most of these were supplements, or herbs.  Here's an outline:

• Prenatal + DHA vitamin (2 pills)
• 4000 IU vitamin D (2 pills)
• Baby aspirin (1 pill)
• Chinese detox herbs (9 pills)
• Antioxidant supplement (3 pills)
• L-Argenine supplement (3 pills)
• Ubiquinol (2 pills)
• DHEA (2 pills)
• Royal Jelly (1 pill)

The detox herbs were great, and temporary, so those dropped off when I started the next step in March, bringing the total down to 16 pills before the RE added in a couple new ones...

This is the thing that keeps me from screwing up with the timing of all the pills each week!

Note: this just holds 1 week's worth of pills...

We met with the RE during the middle of my February cycle just to talk strategy and see what else he would recommend doing now that we've seen all the data from our first cycle.  He recommended an approach he said has been proven successful with low ovarian reserve patients in the recent past.  Since estrogen levels are already very low for me, instead of starting everything off with a week of birth control to calm the system down, we would start the cycle with 3 weeks of "androgen priming" to "charge the ovaries up" and help them respond more readily to the meds.  He then recommended a Menopur only "stim" protocol, combining with the Cetrotide part way through, and then concluding with a double "trigger" shot (Ovidrel) before retrieval.  The round #2 would look like this:

• Day 1 - Baseline blood tests and ultrasound when I start my next period; initiate Estrogen (Estrace) and Progestin (Aygestin) pills at that time
• Day 6 - Start applying Testosterone cream (Androgel, 12.5mg/dl) daily (yes, you read correctly, testosterone cream!)
• Continue for 21 days of pills (ending Day 21) and 21 days of testosterone cream (ending Day 27)
• Day 26 - Blood tests and ultrasound prior to starting shots of Menopur (600 IU daily)

Coming in for the first set of blood tests and ultrasound was a little emotional for me.  It meant we were really starting over, not that I had doubts about doing it.  Not at all.  It just meant that starting meant that we would have to go through the roller-coaster again and the end result would be another potential for disappointment.  I must admit, I was struggling to find my optimism...I felt very apprehensive about getting any sort of hopes up for this round.  I was pretty jolted by round #1 and going from 5 embryos to 1.  Being hopeful seemed like a dumb move, just setting myself up for more disappointment, but I knew being positive was a pretty essential ingredient to making it through the whole process again...and this was going to be an extra looooong process with this 27 days of priming before we even get to start with the shots.  It would be especially long if I have to learn to shave my face / chest during that time, too!  LOL!

I reached out to a few friends who had also been down this road of multiple cycles, all of whom have beautiful babies now.  They sent me pictures and told me I must be positive about it.  They said to look forward to the fact that we know what we are doing, the second round will be easier, even just because you know what to expect.  Keep your eyes on the prize, they said.  Everything you go through is worth it in the end.  It's ok to get your hopes up, because it's so much harder to get through it all without that hope!

Feeling moderately better, and focusing on my positive thinking, we jumped into round #2.  My daily pill count was at 18, and the Estrace and Aygestin were giving me daily nausea.  Yuck.  Bad enough that I stayed home here and there just so I could be near the bathroom.  The testosterone cream was interesting.  It comes as a cream in a pump container, and 1 pump = 1 daily dose.  It had to be sent to a special compounding pharmacy that mixes it to the right dosage.  It sat ominously on my counter top alongside the pill dispenser for about a week until Day 6 arrived.  Day 6 came on March 11 and I took my first dose of testosterone cream.  I felt...the same.  I really hadn't expected the uneventful part of the "priming" phase to be the testosterone.

The 21 days of pills came and went along with waves of nausea, some days better than others.  It drug along and at a few points I wished I could just sleep through the rest of it and wake up on the other side.  For the record, it's not much fun to have the nausea of pregnancy without the actual excitement of the pregnancy!  As we closed in on the 3rd week of testosterone cream, I found myself really wound up about some very silly things.  Twice, I almost went off on people on Facebook.  One was a person posting blatantly false information to conveniently support their political agenda...the other was a set of neighbors who wanted to create and sell commemorative t-shirts lauding their "survival" of the construction of the Grand Parkway (for those who don't know, the GP is a big, modern highway near our neighborhood, one that many other countries would die to have as infrastructure...it was a mild inconvenience for about 2 years before it opened, but the complaining and vitriol that spewed forth from our neighbors would have made you think it was the end of the world! In that moment, I had had enough.).  I rarely would get wound up about either of these enough to reply, regardless of how silly / irritating they might be, and here I was composing very firm responses to each of them, determined to set things right.  Michael stopped me...both times...not worth it at all to respond...it won't change their minds...they are not open-minded individuals, you know this...but I was fuming!  What has gotten into me?  Testosterone!  The rage is real, people!  I also got pulled over for speeding, but thankfully was let off with a warning...

Seriously...why isn't it ever anything good?  My suggestions:
"Makes doing mundane tasks enjoyable" or "May help you lose that 10lbs"

March 31, the last day of the testosterone cream was the day I went back into the office for the clearance check (blood tests and ultrasound) before starting shots.  As they saw at the beginning of March (and also the beginning of the January cycle), I had a medium sized cyst (15mm diameter) on my right ovary.  It hadn't changed size since early March, and appeared to be adjacent to the ovary instead of inside of it, so this was apparently not cause for concern or delay.  The blood tests came in that afternoon and the RE said I was clear to start shots on Friday, April 1.  Hopefully not a foolish decision! Nyuk nyuk...

Acupuncture Overview

Indeed!

I started acupuncture with two sessions during the second week of "stims" in January.  The first visit, I was nervous, but was pretty desperate for anything that might help...or even just take the edge off the stress I was feeling about the whole numbers game.  The RE sent me to Axelrad Clinic, which primarily deals with fertility related treatments.

The paperwork was long, and asked about all kinds of things from family history to current symptoms like bowel movement specifics.  Geez.  The office was small, but nice, and the acupuncturist led me into a room with a few folding chairs and something that looked like an ergonomically shaped, comfortably padded, leather massage table.  We talked for a while about my IVF protocol, my low ovarian reserve, how many follicles I currently had at that point in the "stims", and any symptoms I was having.  He asked about the other medicines / supplements I was taking and if I would be willing to add to that.  My RE said that anything the acupuncturist prescribes will be fine to take with the IVF medicines.  Circulation and egg quality were two big items that the supplements from the acupuncturist could help improve, making it easier for the medicines to get to my ovaries as well as improving the end-product.  Excellent!  I told him I would take whatever he recommended and he drew up a schedule that spread them out throughout the day for maximum effect.  As for the supplements, I bought and continue to buy them from the acupuncturist, but most of them can be found at your local pharmacies.

After our discussion, he asked me to remove my shoes, roll up my pant legs to the knees, and climb onto the table.  Once there, he started with some needles in my feet and legs.  I braced myself, but I could barely feel it.  What a relief!  Once he finished with the legs, he needed access to my lower abdomen.  I had lost count, but knew it was over a dozen needles at that point.  He explained that the needles are so fine that 100 of them can fit inside the opening of a 20 gauge IV needle.  Very tiny!

He put another set of them across my lower abdomen, on my face, and on my wrists and hands.  He then attached e-stim nodes to two needles each positioned over my ovaries.  He clicked it on and asked me to tell him when I could feel it.  I'd used one of these machines before with sick on patches when I had a sports injury.  It sends a small electrical current into your skin and helps enhance circulation in that area, only this time, instead of the stick-on patches, the current would travel through the fine acupuncture needles.  I felt the left side start to tingle, and he dialed the right side to match.

All the needles were in place!  A big fluffy blanket was laid over my legs...right on top of the needles, but that doesn't hurt at all, they simply bend down...and a heat lamp positioned over my stomach.  A CD player was switched on with a soundtrack of relaxing rainforest noises.  He said he would be back in 45 mins and to do my best to clear my mind and relax.

Lying there was a little strange at first, but in reality, this was the first time since starting the IVF protocol that I really concentrated on clearing my mind and relaxing.  I may have even dozed off for a short while.  Since then I have dozed of many times.  It's my weekly relaxation / nap time.  Leaving my treatments, I usually feel like a weight has been lifted and I'm more relaxed.  Whether that's the needles or just the quiet time or both, I'll take it.

The positions of the needles change around somewhat, depending on the symptoms I'm having that week.  There are different nerve trigger points that they target for different remedies.  When I had an awful string of headaches, they would place on on the top of my head, and it seemed to ease the throbbing.

Since that week in January, I have gone back for weekly appointments.  After the first appointment with Chris, the owner, I have seen Jaime for every appointment sense, and she is great.  I've also read a few articles about how acupuncture has been shown to improve the results of IVF cycles.  As we go into round #2, I can't help but hope that will will help our outcome, too.

January/February 2016 - IVF #1, Retrieval & The Waiting

During our last scan on January 23 (a Saturday appointment), we had 7 follicles.  4 of them were above the threshold of size that made my RE feel confident that they were going to be mature.  He said we might only get a few eggs, but we would still go forward with retrieval.  However, he warned that lower numbers may result in us needing to bank/freeze what we get this time and go through it all again.  He knows our hope is to have 2 children, and we needed to prepare ourselves for the possibility of it taking a couple of rounds of IVF to bank up enough normal blastocysts to make that possible.

We administered the "trigger" shot (Ovidrel - which helps finalize the maturation of the eggs and will make you ovulate 35-36 hours later) at exactly 7:45:00pm on Sunday evening, January 24, which was timed precisely with my Tuesday morning procedure time slot.  The goal is for the RE to extract all the eggs directly from the ovaries just before they would be released by the body.

Sunday night, I had a dream that the trigger shot worked too fast and that all my follicles fell out as I arrived at work Monday morning.  They were like little egg-shaped marbles that rolled in all directions across the hard office floor.  I was panicked and started chasing them every which way, knowing my RE would be very disappointed if I couldn't find them all after we worked so hard to grow them with all the shots.  I woke up feeling silly, but later found out this is the "showed up at school naked" dream of IVF and is a pretty common dream theme amongst those triggering.  LOL!

Tuesday, January 26, we arrived at Piney Point Surgical Center around 6am and checked in for my 7:15:00am procedure.  It was early, and we were nervous, but excited.  The nurse took me to the prep room to change and then brought Michael back to sit with me until the RE could some brief us before the procedure.  The IV didn't quite go smoothly...the clip-on tourniquet got stuck on my forearm and ultimately had to be cut off, but not after the IV needle had leaked blood down my hand and fingers.  Old me would have panicked, but new needle-fearless me handled it pretty well.  The nurse apologized and cleaned me up, and then we were waiting again.

The RE came and walked us through it all.  They would bring me into the procedure room, put me under anesthesia, the RE would aspirate the ovaries through my vaginal wall, and suck all the eggs he can from each follicle on each ovary.  The embryologist would be in the room, counting what is retrieved, and then shuttling them off to the lab room next door to evaluate how many are mature enough to fertilize.  Michael would be on the spot to give his donation while I was under.  The lab would take his sperm from there, wash it, and pick the best, healthiest ones to insert into each mature egg.  All of this would happen that exact day.  We would know how many eggs were retrieved before we went home!

They sent Michael back to the waiting room with his paper bag filled with documentation and a plastic cup, and they guided me to the procedure room.  They untied the back of my robe, and I climbed onto the table.  My arms spread and secured outward as they converted the table into the stirrups setup, just like the D&C, except I wasn't scared or sad this time.  I chatted with the anesthesiologist as they started the medicine that would put me to sleep.  The embryologist came in and introduced himself, and I asked him to take good care of my few little eggs.  Then my RE was there, and he asked if I was ready, and I was.  I don't even remember falling asleep, but I'm pretty sure it was soon after that.

I woke up quickly after they brought me into recovery, and I slowly got dressed while the nurse went to get Michael.  Coming out of anesthesia, I'm a bit slow and dizzy, but this was the 3rd time in as many months, so I was pretty capable of getting dressed solo.  The nurse had brought me a bottle of water, and helped me into a wheelchair, where I waited first for Michael, then for the RE.  When the RE said we got 7 eggs, I was shocked and excited.  I was preparing myself for 4 or less, and we got 7?!  How exciting!  We had to wait until the next day to find out how many fertilized, but 7 was amazing news.  Statistically, ~50% of eggs retrieved end up as frozen day 5 embryos, which meant a potential of ~3.5 embryos from this cycle. 50% of those typically implant and produce a baby.

The thought crossed my mind that this may be it...we may have just created all of our children in one go.  The average number of eggs retrieved during IVF is somewhere in the 15 egg range...given my low-ovarian reserve issue, that was way to much to hope for, confirmed by how the cycle had progressed up to now...we just weren't likely to be average from the start.  The thought that we might have the chance to do this once and be finished was exciting and gave me lots of hope.

We drove home, and despite my dietary restrictions, which had been challenging during the last 10 days, I requested my usual post-anesthesia treat of a chocolate milk shake and a cheeseburger...a day with some cheating was in order!  ...which I paid for later with a stomach ache.

The next 6 days were the slowest ever...like waiting for Christmas. The following morning, I got a call from the lab.  6 of the 7 eggs were mature enough to fertilize, and 5 of those were still healthy and surviving after 24 hours.  Wow!! 5!!  Now to wait for more information on day 3 (Friday, February 5, my brother's birthday!).

On day 3, all 5 were still growing, but there was some divergence in the pack.  On day 3, they hope for the embryos to be at least 6-8 cells, >8 is better. We had:

• 1x 4-cell embryo
• 2x 6-cell embryos
• 1x 8-cell embryo
• 1x 10-cell embryo

And then it was the weekend.  Day 5 would be Sunday, and we would find out on Monday how many made it all the way to be 100 + cell embryos, sampled for genetic testing, then frozen.  I couldn't help but think we would get 3 or 4.  Maybe that little 4-cell would catch up?  Could 5 be possible?  They said they have seen it happen...

The waiting was very hard.  I'm not a very patient person in the base case.  Plus, coming down off the hormones meant I felt emotionally shaky, and physically, my entire face had decided to break out.  Delightful, right?  And to top it off, I would be on a business trip to Phoenix on Monday and we would have to find out when we couldn't be together.  At least the numbers were good so far!

Monday morning came and I got the call while I was in my hotel room.  The voice on the phone said only one made it to blastocyst stage.  One.  That's it.  Just one.  It was the 10-cell embryo from Friday.  My heart sunk.  All that effort for one lonely blastocyst, after having 5 still growing 2 days before...which meant we had to try again.  Progressing to transfer this blastocyst to get pregnant, if successful (50% chance on average), would mean only 1 child.  Coming back later for more IVF would likely find me out of eggs entirely.

I asked if the sample was successfully taken for testing on the 1, and the line went silent.  The lab's paperwork had an error, she said, clicking through her system.  It did not show that the genetic testing box had been checked, though that was clearly written in other parts of my file.  She said she needed to check if it was too late, and she would call me back.  When she did, she told me that the blastocyst had been frozen, stored, and not tested.  We wouldn't be able to find out if this one remaining blastocyst was genetically normal.  I hung up the phone and burst into tears, sobbing loudly into the damn hotel pillow...what if this one is really none?  I was sick to my stomach.  All this work, and all the emotional roller coaster of a process we've put ourselves through for one-maybe-none?  I felt like such a failure...6 of my 7 eggs failed and the last one is a big question mark.

Later, I got a call from my RE, and he apologized profusely.  It was a paperwork issue which resulted in the blastocyst not getting sampled before freezing.  They would make it right.  When it came time to do our first transfer, they would defrost the blastocyst, sample it immediately, and send the sample for 24-hr turnaround genetic testing (free of charge) before transferring it into me.  With a transfer, there is a lead-up protocol of a couple of weeks of medicines to prep the uterus to be at the exact right stage for blastocyst implantation.  Just like if the blastocyst had come down the fallopian tube naturally.  If that one blastocyst is abnormal, we wouldn't want to waste the opportunity, and we can defrost another (from our potential round #2, which will be tested and confirmed normal), and transfer it instead.

We talked about round #2.  Second rounds, he reminded me, are often more productive than the first.  He recommended taking a break to give my ovaries a chance to calm down, but said we could go straight into it if we wanted.  I told him a break was in order, especially since I would be travelling for the next couple of weeks.  When I was back in town, we would go to see the RE and discuss the strategy for round #2.  I hung up the phone, feeling very down, but at least moderately satisfied that there was a solution to the "unknown" blastocyst quality issue.

Michael and I agreed that one is better than none, and for now, we should hold out hope that the one is good and normal.  Plus, maybe we would get enough from round #2 that the first one can just be a back-up!  It was still a bitter pill, and the thought of starting over again was overwhelming.  The rest of my business trip was a blur, however I did get to chat with a close friend, who had recently given birth to IVF twins, and she made a very good point.  During a normal cycle, you release 1 egg / month.  Those 6 failed eggs...that's 6 months of trying naturally that we just got to skip.  Potential miscarriages we were able to avoid.  The IVF process allows us to go in, find the best chances for success, and skip straight to them.  The ones we lose along the way, we should be happy that we aren't wasting our time (months and months of time!) hoping that they will be successful, when they weren't meant to be.  While this thought process helped quite a bit, I couldn't help but hope we could do better in round #2 and find a higher percentage of successful eggs / embryos...

January 2016 - IVF #1, So Many Shots

Sunday, January 10, 2016, was the official kick-off of our first round of IVF.  After much discussion, Michael gave me the first shot.  Having received some good advice from a colleague, I tucked a snack-sized zip bag of ice in my waistband while I mixed up the medicines in the syringe.  It was definitely more complicated that I had envisioned, and I laid all the notes and instructions from the nurse on the counter top to follow along and be sure I was doing it correctly.  Some of the medicines (the Gonal-F, Cetrotide, and ultimately the Ovidrel) must be kept in the refrigerator.  With a little back and forth to the fridge and all the bits and pieces, it took me about 20 mins until I had the syringe loaded and ready.

Instructions on left, supplies on the right.

All the supplies for the very first shot!

300 units of Menopur, which consists of 5 vials (1x saline, 4x of a powder pill that would melt / dissolve into the saline upon combination)
300 units of Gonal-F (dosed from a "pen" that you dial in the correct dosage, then push the plunger to dispense that exact amount)

In short, I would put the 300ml of Gonal-F in with the last vial of Menopur, then use the saline to dissolve and combine the other 3 Menopur tablets, finally mixing that 3x Menopur mixture with the last vial of Gonal-F/Menopur combo.  Getting everything mixed and extracting as much of the liquid from the little vials at each step was a bit finicky.  Sometimes bubbles would form and they would cling to the walls of the vial and thwart my efforts to get as much of the (very expensive) medicine back into the syringe.  I would get much better at this as time went on, but the first few tries were a little frustrating.  Thankfully, it wasn't supposed to go on for too long, and we had been told the average person goes through 9-12 days of "stims" before retrieval.

Once extracted into the syringe, the cocktail was ready, the injection needle is twisted on, and it was ready.  Michael would then take it, tap the air bubbles to the top and squeeze the medicine to the tip of the needle...you know, like addicts do in the movies!  I tried to ignore that part while I removed my ice baggie and wiped the spot with an alcohol pad.

No denying it, I was nervous.  I kept telling myself that many, many people do this all the time.  I felt like I was being a wuss.  I have several diabetic friends who would probably laugh a little at the butterflies I was having in that moment.  I pinched the skin on my stomach a couple inches below and to the right of my navel, and closed my eyes.  Michael did it!  I felt nothing.  Suddenly, I felt a bit silly...but I was very glad for it to be so painless.  The injection site bled a little, which led to subsequent shots concluding with a tiny spot bandaid...which also helped us keep track of which side was up next.

Starting that Wednesday, I would go in to the RE's office for an ultrasound and blood test every other business day.  They would check my ovaries, uterine lining, and blood hormone levels then reconfirm the injection dosages going forward.

Ironically the other kind often leads to pregnancy...if I had the option, I would definitely choose tequila. 

We proceeded with this injection routine between 9:30-10:30pm every night for 9 days before they told me my hormone levels were high enough to add in the Cetrotide (which as an ovulation "antagonist" keeps my ovaries from releasing the eggs to early).  By this time, adding a second shot to the process was easy.  The Cetrotide has to be mixed like the Menopur, but it's just 1 tablet vial and 1 saline vial, which now that we were pros at this, was a cinch.  It was also around this point that the RE called a halt to any exercise, strenuous activity, or lifting of any sort.  He explained ovaries undergoing stimulation will grow quite large with all the follicles, and are a bit like "bobble heads"...if they were to twist, say if I were lifting something heavy, it would be extremely painful and also likely cut off circulation to the ovary, which might then die.  Scary, right?  Best excuse I've ever heard to avoid exercise at all costs...

On January 18, the ultrasound was still not showing very much, just a few smallish follicles (mostly on the right ovary), which wasn't very encouraging...it was becoming apparent that my schedule would be longer than "average".  Concern crept over me that this cycle could get "cancelled" for lack of response (meaning that there aren't enough follicles to warrant going through with the retrieval), I asked if there was anything else I could do.  My nurse recommended looking into acupuncture.  She explained that it has been proven to help, and that there's a clinic they highly recommend.  I got an appointment for the next day.  I had never done acupuncture before, but what's a few more needles at this point, right?  I will go into the adventures in acupuncture at another time.  It is worth noting, however, that the acupuncturist recommended I immediately start a few key supplements as well as a gluten-free, dairy-free, caffeine-free, low fat, low sugar diet.  The diet part was almost as hard as the shots at first, but again, more on this later...

On January 20, I had to take a business trip with all my injection paraphernalia.  It was only for 24 hours, and it would require taking all of it through airport security.  Important things to consider (from TSA instructions I read):

• Pack everything together
• Bring documentation of prescriptions
• Ensure medicines are labeled and in original packaging
• If they must be kept cold, ice packs are ok, so long as they are frozen solid as you pass through security; liquidy ones will be taken away

I jumped through all the hoops, prepping for everything, including a backup ziplock I could fill with ice if they took away my ice pack that was keeping my medicine cold.  Packing it all into a neoprene lunch bag, I wedged down into my laptop bag and headed to the airport.  I was so ready...and security didn't even bat an eye when I put it through the scanner.  Could not care less. Sigh...

The main thing about this trip was that I would have to give myself the shots for the first time.  This was intimidating, but I knew I could do it.  In the hotel room, the adrenaline started pumping as soon as I started mixing them up.  What if I didn't stab myself firmly enough?  What if I stab my finger instead?  I held my breath and did it (in the stomach, not the finger)...and the second one, too!  Suddenly I was dizzy (likely from holding my breath for so long), so I left the clean up for later and laid down on the bed.  Here I was in a hotel, two empty syringes on the side table, and I'm sprawled out on the bed gasping for air.  Might have been an misleading scene for someone to walk in on in that moment...but at least I had all my documentation...thank you TSA!

Interestingly and something I had rarely noticed before, most airports and many other public places will have sharps disposal units in their restrooms.  The next day, I was able to dispose of my used items at the airport ladies' room before going back through security.  I had one more day's worth of medicine with me, just in case there were major delays, but in the end, I made it back to Houston and home just in time for Michael to give me the next set of shots. 

In the end, we would go through 15 days of shots starting January 10, ending with trigger shot on January 24 and retrieval on January 26.  They might have kept me on them longer, except that my estrogen level started to plateau, meaning it was time for extraction, whether the follicles were all ready or not.

All of the medicines taken during IVF round #1.  Each Gonal-F pen contains 3 doses.

Overall, the cycle wasn't miserable, not like the horror hormone reaction stories I had heard from some, but it wasn't easy.  My stomach was sore from the shots, and as the follicles grew, I was feeling bloated and uncomfortably pinchy on the inside.  I had a confetti of little bruised spots about the size of dimes at the injection sites, at various stages of fading.  It was around this time that I was getting pretty regular headaches and felt generally exhausted.  There were a few mornings when I just couldn't get going on time...sleep just felt far more important and getting up was far, far too hard.  I was very fortunate that I could work from home when I wasn't feeling great.  For the days I went into the office, I bought stretchy work pants made of yoga pant material (which were clutch), which I wore religiously as I started to feel more and more uncomfortable.

The most publicly visible symptom of the "stims" was behavioral. I got very absentminded and flaky.  It was reminiscent of when I was pregnant...total "baby brain".  The more self-conscious I would feel about it, the worse it would get.  Anything important had to be written down, and even then, it was a gamble if I would remember.  I put the majority of my efforts into remembering things for work, and let the rest of the chips fall as they may.  The stress of the shots, the constant numbers game of the follicles and their sizes, and the extra stress of forgetting things left and right led to some emotional breakdowns.  Maybe the hormones made me more susceptible, but thinking back, there were tears on a pretty regular basis throughout the process.  Usually just short bouts of emotion, but sometimes longer...and Michael was always there.  The whole cycle took a lot of teamwork, and not simply with Michael giving me the shots.  He was so understanding and patient with my forgetful and emotional self, gently saying, "You just told me that a minute ago," or the many times he said, "Don't forget..." to help keep me on track.  I'm certain it was testing his patience on several occasions, but he rarely let it show.  And for the last week of shots he was extra-protective of my "bobble heads"...he did all the lifting (physical and emotional), even including my purse when we would go places.  He was completely there for me and helped prop me up every day, which I know was exhausting, especially with several other stressful events at work and with family playing out at the same time.  he was (and is) my hero, and despite being in a fragile emotional and physical state, I felt so protected and loved.