June 2016 - IVF#3, Embryo Genetics

Genetics test results arrived today.  Our single frozen embryo from round 3 is abnormal.  It has been diagnosed with Turner Syndrome, and our RE does not recommend using it for transfer given the complications that come along with it.  Turner Syndrome isn't indicative of any additional challenges, nor is it related to my diminished ovarian reserve.  It's a common abnormality, and we were just unlucky enough to have this happen on top of what we are already dealing with.

We are both heartbroken that we are back to 1 embryo.  So much effort just to be back where we were in February.  IVF = Isn't Very Fair...remember?

Round 4 birth control has already started.  Tentatively moving to shots around end of next week.  We will meet with the RE tomorrow and talk more about the genetics and strategy for round 4.  More to come...

June 2016 - IVF #3, Embryo 2 Failed

Our second embryo from round 3 degenerated on day 7 (Saturday). We knew it was not likely to succeed from day 3 when it was only 3 cells and fairly fragmented, but it was still disappointing to get the official confirmation. They are each a part of us and have been the focus of so much energy and hope. There were some tears, but there always are when we lose one along the way.

We are very happy to have added one to our frozen inventory, now totaling 2. This is still a big success for us. 

Michelle said the earliest we would likely hear back on the genetics for our newest blastocyst would be Monday, June 20. A little over a week. And it can take up to two weeks.

I did allow myself for a short while to think about the wonderful, albeit more remote, possibility of this third one making it. With 3 we could have considered trying a single transfer to see if we could get lucky with our first one, leaving 2 for later use. With just 2 at this point, even if the genetics come back normal, we are leaning toward another round. 

Once we know, we will set up an appointment with our RE and regroup on the strategy. In the meantime, we wait. Wait for genetics and, less exciting, wait for my period to come (can't start the next step without that happening...TMI? If so skip the next paragraph). 

The latter has been made exceptionally uncomfortable by the heavy hormones used in this process. So bad after round 2 that I stayed in bed for the first 36 hours doubled over in pain. The nurse says it's normal, so I'm just going to have to deal. As the hormones come down, it usually kicks in about 7-10 days after retrieval for the average woman, but has been 15 days after retrieval for me each time. Perhaps because I'm on the higher dosages. 

At any rate, for now, we are between cycles, and I'm taking a reprieve from the NFD. I will still go to my weekly acupuncture sessions, which will help me deal with the anxiety and stress of all the waiting. That and the occasional chocolate milkshake! 

June 2016 - IVF #3, Day 6 Report - Embryo 1 Success!

WE DID IT! With the help of many nurses, lab staff, and a fantastic RE, we doubled our frozen embryo inventory today (now 2), putting us one step closer to our embryo goal!

I got the call while touring our rubber plant and had to wait until we were finished and back in the office to check the voicemail. Safety first!

The 6-cell embryo from Day 3 was biopsied and frozen this morning. The 3-cell is still growing, but not yet to blastocyst stage, so they will give it another day. It's progress is not promising, but stranger things ave happened. They will call me again tomorrow at the usual time. 

It will take ~2 weeks for the genetic testing to come back and assure us that this embryo is normal. More waiting, but of course!

Lots of emotions and thoughts today. Mainly relief and joy for some long-overdue good news! More to come on this front later.

June 2016 - IVF #3, Day 5 Report

Today was my day to present and lead a discussion during our workshop. In a room full of manufacturing guys at our Pensacola facility while skype connected to another room full of manufacturing guys (and one girl!) in our sister plant in the UK. My time started at 10:30am, and as luck would have it, Michelle called about an hour into my 2 hr time slot and I couldn't answer. My phone glared at me with a "missed call & voicemail" notification for a whole hour.

When I finished my segment of the agenda, I had successfully directed a development meeting on global supply-demand balances for next year's plan and had nearly passed out from the anxiety of knowing that the Day 5 report was sitting right there on the conference room table next to me.  I can't tell you how many times I wanted to just get up and say, "I'm sorry, but I have to get this."

I was preparing myself for the worst. If it was 0 embryos left, I would manage through the day as best I could. When my presentation was finished, I hesitated. Fear gripped me as I hovered over the unplayed message. One I hear it, this round might be over. In this moment and to me, my embryos are still alive. I took a deep breath and played the voicemail. The rest of the group was grabbing boxed lunches. I spun my seat around so they couldn't see my face, just in case.

Michelle said, "Hi Kelly, just calling with your Day 5 results. So, neither of your embryos made it to freeze..."

My heart stopped for a fraction of a second, adrenaline pumping, and I held my breath, but she continued on.

"...but they have made it to a slightly earlier phase called 'morula', so hopefully we will see more progression tomorrow and get them frozen. I will give you a call back tomorrow to let you know how the extra day goes!" 

Damn, Michelle! You just scared the crap out of me!!

I chuckled and breathed a big sign of relief. It's not over yet! This is pretty good news. They are both still progressing and on a similar 6 day track as some of our previous ones. 

Morula, I learned today from a friend, comes from the Latin word for 'mulberry', and that's pretty much what the embryo looks like at this phase. More cells than is worth counting, but not the 100+ of a blastocyst. Of course round 1 saw many drop at this point just shy of the finish line, and day 6 was when we lost our single round 3 embryo. This result is still far better than 0.

Embryo stages

Reference Blackberry

 So tomorrow is business workshop day #2, embryo day #6, IVF round #3 / day #27, and month 30 of this whole trying to have a family business. Exhausting.

Indeed.

At least I get to go home to Michael tomorrow afternoon! I can't wait! No matter what happens tomorrow after Michelle calls for the final time this round.

June 2016 - IVF #3, Waiting and "It just takes one"

I worked the rest of Tuesday with a break for acupuncture.  I joked with my acupuncturist that I would rather that they kept me under anesthesia until the results were known instead of all this waiting.  Selfish and unfair to Michael (unless he could join me!), it would be tempting if it were a possibility.  I have said it before and fully admit, I am not a very patient person.  

When I got home Tuesday evening, it was back to work until almost 4:00am Wednesday getting data in order for a business trip to Pensacola.  Yep...getting on a plane and leaving town means I will be alone (again) when I get the Day 5 report.  

You may recall, round 1 went this way.  I was in Phoenix on a business trip when received the news that we had gone from 5 embryos on Day 3 (4 of which were deemed "on track" 6-10 cells each on Day 3) to 1 lonely blastocyst, which felt like a substantial loss. To make matters worse, they neglected to sample it for chromosomal testing before they froze it because the lab paperwork wasn't filled out properly.  We now can't find out if that blastocyst is normal until the day of transfer (after an overnight rush test that they will pay for due to their mistake).  I sobbed out my frustration into my hotel pillow, then gathered myself the best I could to join the work meeting I was there to attend.  I once had a severe sinus infection on a long business trip that kept me holed up in a hotel for 2 miserable days of the 2 week journey...I would rather endure that trip several times over than go relive the emotional roller coaster of round 1 results alone again.  

You might be thinking, "Well, gee, Kelly, you still were able to get 1 frozen blastocyst from round 1, better than round 2!  Shouldn't you be thankful?"  Let me explain.  I am exceedingly grateful we have the 1...even if it is a question mark for normalcy.  Round 1 was the hardest and scariest, primarily due to neither of us knowing what to expect.  When we had 5 embryos on Day 3, I allowed myself to relax a little and I got very excited about the possibility that this could be all that we need - just 1 round and we are set!  Even if we just got 3 of those 5 over the finish line, that could be all we need.  I could be pregnant in another month or so!  Have my baby before the end of the year!  I saw the light at the end of the tunnel, and it was such a relief.  That hope came crashing down with the disappointing Day 5 news, and we were dragged back into the trenches.  Hope. Then disappointment.  That's been the reality of IVF in our experience, hence my moderated expectations in round 2 and now round 3.

I hear, "It just takes one!" so often.  They are innocent words of encouragement, and I appreciate the intention.  Embroiled in the IVF process after 3 rounds, they often feel sour.  When I hear, "It just takes one!"  It can feel like a judgment on our strategy...already having one on ice.  I do have "one", but there is still a chance it's actually already 0, and we could have the data on that, but don't due to stupid paperwork.  Statistics say it's a ~50% chance of pregnancy when you transfer a chromosomally normal blastocyst back into the womb.  That tells my inner statistician that it takes at least 2 to have the best chance to have 1 baby. 

2 blastocysts x 50% = 1 baby

We are trying (maybe in vain?) to bank up a few extras in the hope of having 2 children.  

Our RE's target from the beginning = 4 blastocysts x 50% = 2 babies.  

I know...the first one could take...the second one could, too!  There is a coin-flip chance that 1 blast = 1 baby.  There's also the possibility that 4 blasts = 0 babies.  

From my point of view, it sums up like this:  My ovaries are giving out.  We are officially up against an awful and seemingly unfair clock that God felt was appropriate to fast forward by about 10 years.  Once the ovaries give up, and they get closer every day, there is no coming back.  I do not want to place my hopes on a coin-flip chance unless I have given my eggs and ovaries their best possible shot.  Now is the time to work as hard as I can toward a statistically sound chance, which to me is more than a single coin-flip.  Some days it feels more like throwing darts while blindfolded...sure, it just takes one dart to hit the bulls-eye, but what are the real chances of that happening??

Indeed, it does just take one, I get what is meant by this statement.  "Have hope, it could be the perfect one."  The one that is meant to be.  The odds could come around in our favor and our original lonely one becomes THE ONE...maybe the ONLY one that we get.  I have heard several real stories of couples with one lonely blastocyst, and at the end of the day, that's all it took for them!  If that becomes us, we would count ourselves incredibly lucky and be forever thankful.  My inner statistician reminds me that there are just as many couples on the other side of that coin-flip.  Luck and odds have not been in our corner with this process so far.  I hope this helps explain why I see the one we have as not enough to stop trying for more.  A coin-flip may be all we end up getting, but it won't be for lack of trying for better odds.

June 2016 - IVF #3, Retrieval & Day 1 & Day 3 Reports

It has been a while since I’ve provided an update.  Several of you have texted, and for that I’m very grateful that you’re interested in getting the latest!  This is the most critical time of round 3, but I have found myself flat out of energy at the end of each day since the retrieval.  Thank you for your patience, and I’ll get right to the state of things, which have been busy, and exhausting, but (spoiler alert!) if you saw the title of this post includes "Day 1 & Day 3 Reports", you have probably already figured out we had some level of success.

The Retrieval:

Retrieval Selfie!  Feeling fairly confident and cheery post-IV, waiting for them to bring Michael back to wait with me.

The retrieval on Saturday went fairly well, but did not yield the 4 eggs we had expected.  Perhaps I jinxed it by saying we haven’t had this issue yet…Two of the follicles, the larger ones on the right, were ultimately “empty” follicles.  This is a bit of a misnomer, as a follicle can’t exist without an egg inside, so what it means is that the egg did not develop properly and likely remained stuck to the inside of the follicle wall.  When the RE flushed and drained the follicle, the egg remained inside the follicle, and being very tiny, the equipment can’t find it and knock it loose.  In all likelihood, those two eggs were not chromosomally normal due to a bad initial division (i.e the 46 chromosomes often don’t split to perfect 23-23 pairs). 

As reassuring as it is to know that these eggs were a lost cause from the start, it was disheartening news to hear upon waking up from the retrieval, which I had gone into with more calm and confidence than either of the previous two.  “We were only able to retrieve 2 eggs,” rang in my ears for the rest of the day.  In my hazy and exhausted state, I felt tears rolling down my cheeks as we drove away.  We had worked so hard and long for those 4 follicles to grow (total of 80 injections and 10 blood draws), and now the chances that this could be our lucky / final round were abruptly halved. 

The new reality: If we get one blastocyst from this round, we should consider ourselves lucky.  On the bright side, that would double our inventory of blastocysts from 1 to 2 on ice.  But more to come on our thoughts and feelings about this.  I promised a quick summary to get you up to speed on what’s happening now…

After waking up from this retrieval, my ovaries felt more swollen and angry than usual.  I made a mental note to remind them that if they were to simply cooperate, we might not have to do this again.  The nurse gave me some heavier pain medicine…I’m guessing that the extra efforts to flush the follicles on the right were to blame.  The rest of the day Saturday was spent sipping my chocolate milkshake (tiny victory!) and sleeping.

Day 1 Report:

Sunday morning I woke up intensely sore and anxiously waiting for the day 1 report, which wouldn’t come until a little after 10am.  Michelle, the sweet-tempered lady whose job it is to deliver the fateful news, was on the other end of the phone.  She said BOTH eggs were mature, and they BOTH successfully fertilized!  We were very relieved…neither of us wanted to be back in the 1-embryo situation of round 2. There is still a chance for both of them!  Go lefties, go!

Hanging up, I knew that the next update wouldn’t come until Tuesday morning, which felt like FOREVER away, but at least we had some hopeful news to tide us over until then.  Plus, this week has been tremendously busy with work.  If I could have chosen, this week of IVF events and this week of work would NOT have overlapped.  Every year we hit a peak level of activity around planning the following year’s budget and targets…this is all happening now.  Additionally several senior managers were in town, and working remotely (on Friday before retrieval, and Monday post-retrieval) wasn’t as solid an option as it had been in the last two rounds.  I tried to be stealthy about my discomfort standing and sitting, but I'm guessing I looked a bit like I had overdone it at the gym.

The benefit of all this activity, is that the time has seemed to roll by quickly, and while waiting is still the worst part of this whole process, at least the Sunday to Tuesday morning span wasn’t completely torturous.  I did my best to think happy 8-10 cell thoughts!

Day 3 Report:

Tuesday morning came and I turned my phone ringer on around 9am and I carried it everywhere just to be sure I didn’t miss the call.  Thankfully the soreness from the procedure had mostly abated, now it's just the waiting.

Michelle called at 10:30am with the day 3 report.  Both embryos are still growing.  Partial relief!!  When they checked on them that morning, one was exactly where they would expect, 6 cells and with 0% fragmentation.  The other is growing slowly at 3 cells and with 25% fragmentation (similar to round 2).

6-cell embryo (not mine, just from Google)

Not bad news…there is still a reasonable chance for success of round 3.  For those of you curious, here's an explanation of fragmentation that I found helpful:

• "As cleavage embryos divide, sometimes a small portion of cytoplasm breaks off and forms a fragment. Fragments are not considered cells because they do not contain nuclei. The cause of fragmentation is not understood completely, but it is thought that embryos that contain a lot of fragmentation are at a disadvantage because the embryo loses a lot of the cytoplasm needed to sustain the cell." 

This means that a slow-growing embryo with fragmentation is not a great sign.  Not impossible, but not likely to make it.  We have had 2 embryos perform this way before...neither made it.

While I had been thinking happy thoughts up to that point, the realist in me had worked hard to keep my expectations in check…I knew from the start that for an average person, only 50% of eggs retrieved can be expected to make it to blastocyst stage.  Plus, we know from our own rounds 1 and 2, that our individual experience indicates our chances are less promising.  The news of the 6 cell embryo was wonderful to hear, looking as proportional as it can at this stage, and seemingly on track. 

There is definiltely worse news that we could have faced at this point.  Next update isn’t until Thursday morning (day 5 of embryo growth).

June 2016 - IVF #3, Day 21 of Shots - Trigger Time!

This morning's check went well, and all 4 of the follicles are now in range!  The right ones are 21mm and 19mm in diameter, and the left ones are 16mm and 15mm in diameter!  My estrogen is now a whopping 1200pg/ml.

Around 3:30pm, I got the call from my nurse.  It's finally time to trigger!  Our instructions are to take the trigger shots (2 of them) at precisely 10:00pm.

Here's a chart I made from my portal data with my blood test and ultrasound results from all the checks after starting shots.  The line shows how my estrogen changed and the bars represent follicle diameters and how they changed from start to end.  While the follicles will continue to grow, I won't get another scan before the retrieval, so this is as complete a picture as we will get from cycle 3!

Red bars are right ovary follicles, blue bars are left ovary follicles.

My retrieval is scheduled for 9:30am on Saturday morning, and we will need to be there to sign in at least 1 hour ahead of that.  We also live about 1 hour away from the surgery center where this procedure takes place.  Over the course of the last couple of weeks (and months), it has been raining heavily and flooding in Houston.  We may need to allow some extra time for finding alternate routes if it doesn't ease up by Saturday.  Flooding should NOT be the reason this cycle fails!

I'm so happy to be finished with the shots routine and on to the next step, though the next phase (retrieval and embryo growth) is probably the most difficult for me.  Not so much the retrieval itself, but the helpless waiting afterwards.

Retrieval process feels fairly routine to us at this point.  The only worry I have regarding the retrieval is if they can't find as many eggs as we have follicles.  This happens sometimes...they are called "empty" follicles.  Either the follicle doesn't have an egg, or (more likely) the egg didn't fully mature and detach from the wall of the follicle in a way that it could be sucked out.  It would be a disappointment if we worked hard to grow these follicles and then didn't get the egg from them, especially with our small numbers.  For those ladies with a few dozen follicles at this stage, losing a couple eggs is a much smaller impact.

Here's a cartoon of how a retrieval works:

Using an ultrasound probe equipped with a long needle, the RE will perforate the wall of the vagina and into the follicle within the ovary, sucking out all fluid, and hopefully the egg with it!  Rinse, lather, and repeat for each follicle...

Here's a video of what it looks like as the RE aspirates the follicles (black & white ultrasound view, not scary or graphic).

Just like the last two retrievals, my RE will come see us in the recovery room and let us know how many eggs they were able to retrieve.  We haven't had any empties so far, so here's hoping for 4 happy, healthy eggs!

Once they have my eggs, and Michael's donation, the process is the same as before.  We aren't sure yet if they will tell us the next day (because it will be a Sunday) about how many of them fertilize successfully and start growing.  The usual checkpoints are 1 day after fertilization, 3 days after, and 5/6 days after, meanwhile there is absolutely nothing either of us can do about it but wait.  Regardless, by Friday next week, we should know the outcome of this cycle.  Hopefully we will have an embryo (or two?) that we can sample for genetic testing this time!

For now, I'm going to focus on my favorite part about the retrieval:

A big 'ol Whataburger chocolate milkshake on the way home!!!  ...aaaand a reprieve from the NFD!

June 2016 - IVF #3, Day 21 of Shots

Today is day 21 of injections...Day 19 of the heavy stims.  This cycle has been exhausting.  You know that feeling you get when you are about to get sick?  Like your body is worn down and working in overdrive to fight off the bug.  Arms and legs like jello and brain is foggy.  That feeling took over during the second week of shots and settled in for the duration.  This grogginess is accompanied by soreness and bloat in my lower abdomen (partly from the 4 shots a day and partly from my swollen, angry ovaries) as well as the occasional need to burst into tears...thanks hormones!  I'm feeling a bit of a wreck, as you could probably guess.

Day 21.  I did NOT think this round would go this long.  The first round was 15 days of injections, the second was shorter (albeit unsuccessful).  Before you think it, I'm not even close to giving up.  I would do this another 21 days if it would ensure us good eggs.  I would probably break down and cry long and hard if it was going to be that much longer, but I would put my big girl panties on and get it done.  Thankfully the big girl panties can stay in the drawer because we are now close to the end.  Also, why do we still have different words for men's and women's underwear?  Since we womenfolk no longer don pantaloons, isn't it all just "underwear"?  A friend of mine at work is potty training her daughter, and her son, a 4yr old, was rightfully confused as to why his sister has "panties" and he has "underwear"...but I digress.

As of yesterday's scan we are in pretty good shape.  Yesterday was the third check since Sunday (yes, they had me come in on a Sunday - follicles don't stop growing on the weekends!) and the 9th ultrasound and bloodwork check since starting shots.  We have 4 strongly growing follicles, two on each ovary, and a couple of tiny ones.  The 4 had diameters that measured 19mm, 17mm, 14mm, and 13mm.  The target range is 15-24mm, and since my estrogen level is continuing to increase as planned, they wanted to give them all another day to grow.

Here's the calendar so far for round 3:

Today will be draw #10 since shots started and draw #God-knows-how-many for this fertility process as a whole.  Yesterday I asked the blood draw tech, "Lori, are you sure there's any left in there to take?" She smiled sympathetically, said, "Well, let's see!".  She rubbed the tender bend of my right arm looking for a vein where a quarter-sized bruise has formed.  She took some more, wrapped me back up, and gave me a big hug before leading me to my exam room for the ultrasound.  I barely feel it anymore, and I even have the constitution to watch them doing it, which I never used to have.  I remember telling her how "I really don't care for needles" during the first visit, adrenaline starting to throb through my veins in anticipation of the needle.  Almost funny to think of now...

Today's check will determine whether we keep going with shots or if we trigger tonight.  My nurse told me to have medicine through Friday, just in case we needed to keep going, and once FedEx arrives today, we will be all set on medicine, either way we go.

When my RE decides that it's time to trigger, this is what happens:

• I will not take my evening shots of Lupron and Menopur
• Instead, I will take 2 simultaneous injections of Ovidrel, aka "trigger shots", which will be the last of the injections for this round
• These are the ones I wrote about before.  The active ingredient, HCG, is also commonly used as a performance enhancing drug in sports.
• Some IVF patients will only take 1 trigger shot (I just did 1 in my first round); since this medicine helps the eggs finalize their development and achieve maturity, my dosage last round and this round has been 2 shots.
• The nurse will give me a precise time to administer the trigger shots...to the minute.  This time coincides with my retrieval, which will be scheduled exactly 36 hours later.
• They make you sign a form specifically acknowledging this responsibility, and they remind you at several points along the way how important this is.
• The goal is to extract the eggs from the follicles before the follicles release / ovulate them naturally.  If the timing is off, and I ovulate before retrieval, there is no way for them to find the eggs.
• After the trigger shots, we wait and make sure we show up exactly when we are supposed to for the retrieval procedure.
• At this point, if we trigger this evening, the earliest our retrieval can be is Saturday morning.

Since we are day-to-day at this point, I will go to my check today and wait to hear back from them once my blood tests come in and my RE reviews them (usually around 2pm).  Following instructions to a T!  My mother probably thinks that's hilarious...