September 2016 - IVF #4, Day 3 Report

All 3 are still growing!  Waiting for the call was terribly hard today, and I finally talked with Michelle at 3:30pm.  If you remember from previous rounds, Day 3 results are most promising when the cell counts are 6+.  We have 1x 8-cell and 2x 5-cell embryos, which is pretty good news!  My hope for today was for none that had either a) stopped growing or b) were still in the 3-4 cell range...so by that definition, today is definitely a success.

Here's some data from all of my rounds to help put it into perspective.

Green bars represent embryos with 6+ cells on Day 3, yellow are questionable, orange are not good.

We are not out of the woods yet, of course.  As you may also remember, Day 3 results aren't a guarantee of success to the end.  Oftentimes aneuploid / incompetent embryos will peter out and die in the Day 3-5 time frame.  For example: only our 10-cell embryo from round 1 made it to the blastocyst to be frozen, even though we had 3 others that were in the 6+ range on Day 3...

Day 5 report for round 4 will come on Saturday morning, Oct 1

More to come on Saturday...

Embryo Stages

Here's a neat page from the Advanced Fertility Center of Chicago with some photos of embryos starting with Day 1 post-retrieval and going through to blastocyst phase.

September 2016 - IVF #4, Retrieval & Day 1 Fertilization Report

Retrieval yesterday went fairly well.  My doctor wasn't available this time, so my retrieval was performed by another doctor in the practice.  She came to speak with us before the procedure.  I had already changed into my gown and egg socks and the nurse had IV-ed me up (took two tries this time...one in each hand).  She was very friendly, and introduced herself as the chief of surgery for the practice.  We had a nice talk before the procedure, and felt assured that we were in good hands.

In the end, I woke up extra sore and the nurse brought Michael back to see me quickly, which was nice.  We found out from the doctor that only 4 eggs were retrieved from my 5 follicles.  The final egg just wouldn't release from the wall of the 5th follicle, which probably means it hadn't matured properly.  She had tried a few different angles to be sure it wasn't just being stubborn, which explained the extra tenderness on my left side.

She then told us the good news.  The 4 eggs that were retrieved were all MII level of maturity, which is great news, but I won't lie, I wanted all 5.  Having the numbers narrow  straight out of the gate isn't much fun.  Still, 4 mature eggs is a better result than the last two rounds combined, and we felt happy about that.  The nurse gave me some Norco for the extra pain, and once Michael helped me change back into my clothes, they gave him my discharge paperwork.  They always take me to the parking lot in a wheelchair, which is a good thing, given how woozy I am coming out of anesthesia.

On the way home, I got my usual chocolate milkshake!  Hooray!!  But I was exhausted, so the rest of Monday I mostly slept.  I was more sore than the last 3 rounds thanks to that stubborn 5th follicle, and the extra meds were taking a toll.  Michael helped me get up when I needed to and brought me lots of fluids.

Today, I didn't set an alarm, just slept and rested as long as I could and woke up very sore, but better than yesterday.  I needed the rest to recover, but I also knew the longer I slept, the sooner I could skip to the part of the morning where I got the phone call from Michelle with the fertilization report.

Distracting myself by catching up with work started around 8:30am...Michelle called at 10:45am.  3 of the 4 eggs fertilized and were growing successfully as of this morning.  Another lost in the process, but still 3 going.  This is normal attrition - ~80% fertilization success - and similar to what we had already experienced:  5 of 7 in round 1, 1 of 2 in round 2, and 2 of 2 in round 3.  I was happy and sad, but mostly happy.  So much work and hope goes into each of these eggs, so whenever one doesn't make it to the next step, there's a little grieving that takes place for the little hope that is lost.  That egg or embryo is simply not meant to be the one, and this will unavoidably happen as a part of this whole process.  The odds of perfection are slim to none, and each update is likely to contain news of loss.  Intellectually, we know that <50% of those that fertilize successfully will make it to blastocyst stage.  Still, it's not easy to cope with each narrowing of the field.

The next news will come on Thursday morning.  The Day 3 report will be all about how many are still growing and how many cells they are.  8-10 cells each is preferred.  <6 isn't great news, but isn't definitive.  It's a bit of a purgatorial report, but it's at least an indicator of how things are going toward a day 5/6 blastocyst stage.  For more info, check back to my prior rounds for descriptions of embryo growth stages.

September 2016 - IVF #4, Trigger Time!

Wednesday's check showed good progress, and I asked for a printout of my left ovary scan, so I could show what the 3 left-side follicles look like on the ultrasound.  The black blobs are the fluid-filled follicles, and in this shot they are measuring about 14mm each in diameter:

Black blobs are the 3 follicles on my left ovary.  Sep 21 ultrasound, day 9 of stims.

Thursday evening, I mixed my shots with a glass of wine.  2011 Jordan Cabernet Sauvignon.  It was a good pairing.

3 shots, from top to bottom:  Gonal-F, Cetrotide, and Menopur, paired with a beautiful Alexander Valley Cabernet

Friday's check continued to show good progress, to the tune of about 1mm / day for each follicle.  All of the follicles were in the 16-19mm range, so very close, but not quite ready for trigger.  My RE prefers that the lead follicles are 20mm before triggering.  We were called back for a Saturday (today) scan and blood test down at the Piney Point location west of downtown.  After the check today, this is what round 4 has looked like:

Bars represent follicle diameters (red = right ovary, blue = left ovary), and the trend line is my estrogen level

Friday, my estrogen level was over 1300 ng/ml, which is a personal record at this point in an IVF cycle.  Saturday/Today, as you can see, it has plateaued quickly, which means it's time to trigger.  I got my instructions to take my trigger shots (2 ovidrel shots and 1 lupron shot) at 11:00:00pm this evening.  With the lupron included, they need me to come in for another blood test tomorrow morning before I take the second lupron shot at 11:00:00 am on Sunday.  I'm not fully sure what they are looking for in these tests, but it will be estrogen, progesterone, and LH that will be tested.  I will ask for more info on why they perform this extra test, which wasn't a part of our prior rounds (none of which included the lupron trigger).

So, at this point, this is what round 4 has looked like, and will hopefully look like post-retrieval.  Assuming they can retrieve some good looking eggs from my good looking follicles, next week will be the week of waiting on the embryo reports:

September 2016 - IVF #4, Progress!

Today's check went well.  We have 5 follicles (2 on the right and 3 on the left) that are doing very well and are measuring between 10-13mm diameter each and a few smaller ones that may or may not come around.  My doctor wants me to start the Cetrotide tonight, which is an additional shot that keeps my body from ovulating the follicles that have formed, allowing them to keep on growing to the right size for retrieval.

For the visually inclined, the current cycle looks like this with today being Day 7:

After my test results came back today, this is what the follicle and estrogen progress looks like so far:

So far this is looking better than rounds 2 and 3.  We need these 5 (or more??) to keep progressing evenly up to ~20mm diameter each.  Next check (as the graphic above shows) will be on Wednesday morning. In the meantime, this is what the next two nights will look like, circa 8pm.

One day's worth of shots (3): Left: Menopur, Right upper: Gonal-F, Right lower: Cetrotide

Additionally today, my doctor put me back on the thyroid medicine...it seems my TSH levels have gone back up out of ideal range, so back on the Synthyroid pills for the foreseeable future.  This came as a result of the refresh of my annual blood tests.  Remember the photo of a dozen or so blood vials from September of last year?  Yeah, we did 10 of those vials again last Tuesday...yaaaaay...  Thankfully the TSH levels were the only surprise.  All other tests were normal / negative, showing no new concerns.

On a lighter note, the chorus of LMFAO's "Shots!" is currently the soundtrack in my brain every evening during this phase of the process.  I have seriously considered making it my shots alarm soundtrack.  Warning for the easily offended or those who do not enjoy rap, crude adult language is involved...

September 2016 - IVF #4, Shots!

I started the estrogen pills on Wednesday, Sept 7, after a good blood test showed that I had in fact ovulated.  Yay!  If I hadn't, they would have tacked on some progesterone pills on top of the estrogen.  Thankfully, I just had to contend with the estrogen.

The estrogen pills are called "Estrace"...and Estrace and I don't get along.  These are the same pills I took during the androgen priming for IVF #2, and they give me pretty awful, breathe-deeply-or-you-might-hurl nausea.  I missed work on Monday this past week because of this luckiness, camping out near the bathroom just in case.

My cycle started on Monday night, after only 5 days of the Estrace.  They had told me it would likely be 7-10 days until my cycle would start.  After a check (ultrasound and blood test) on Tuesday, my doctor told me I should start shots Tuesday night.  This cycle will look like this:

• 300 units Menopur and 300 units of Gonal-F daily (2 separate shots at the same time each evening).  These are what they call the "stims" or stimulant medicines.  This is the same mix I took in round 1 and round 3.
• After a few days, and once my estrogen and LH blood levels rise to a certain level, I will be instructed to add in 1 shot of Cetrotide at the same time each day as the stims.  Cetrotide is an ovulation antagonist, which helps keep me from ovulating the eggs I'm growing.  
• When the follicles are all in the right range (usually ~20mm in diameter for as many of them as possible), then they will tell me to take a set of trigger shots.  This time, we are doing 2 Ovidrel shots (as we've done for the last two rounds), and this time we are adding in a shot of Lupron. 
• If you remember from past rounds, the purpose of trigger shots is to help finalize the maturity of the eggs inside the follicles just before retrieval.  Usually only mature eggs will successfully fertilize.  
• Its also during this final step in maturity where the chromosomes in the egg cell split, and they need to split properly and evenly in order to be high-quality, chromosomally normal eggs.  
• Trigger shots are very time sensitive, since they will prompt ovulation between 38-40 hours after being administered.  My retrieval procedure is always scheduled for 36 hours after they tell me to take the trigger shots so they can extract the eggs at their height of maturity, but before they are released into the fallopian tubes (where they can't be retrieved).
• Retrieval procedure will follow and will be the same as all of my past rounds.

I was very happy to start shots earlier than expected, and that baseline check on Tuesday showed that both ovaries had some small follicles already forming, but none so big as to threaten to be a dominant follicle (like in round 2).  

Friday's check went well, and already showed 2 follicles in the 8-9mm diameter range (one on each side) with a few smaller ones in the background on each ovary.  I was relieved to hear we had several showing up, and that they were all in fairly close range with the smaller ones in the 5-6mm range.  If they all keep growing with a similar pace we might end up with a better total follicle count going into retrieval.  

I've been asked if I'm nervous about starting shots again.  In the first round, the shots were definitely the most intimidating part.  This time, I'm happy to be back to the shots.  First of all, the estrogen pills were so unpleasant that I would rather be stuck with needles, but also moving on to the shots / stims means that we are actually growing eggs!  Plus, the fear of the needles is essentially gone now.  I don't even need to ice before the stim shots anymore.  (For future reference, I reserve the right to change my tune on ice when / if we get to go to an embryo transfer...that will mean intra-muscular injections of progesterone oil into the buttocks muscle, which I have heard is an actual and severe pain in the ass.)

For now, being back in the routine of shots feels like a good thing.  I'm trying to take it one day and one check up at a time.  This coming week, I'm booked in for ultrasounds and blood tests on Monday, Wednesday, and Friday.   I already have the familiar quarter-sized bruise on my right elbow from the two blood draws last week.

For some extra info, see my post from round 1 that explains the IVP process as a whole.

August 2016 - IVF #4, Here we go again

Vacation and the two California weddings went well.  It was nice to see friends, drink some wine in Sonoma and Napa, and even nicer to have several weeks of 0 doctor visits, 0 blood tests, 0 ultrasounds, and 0 shots.  So nice, in fact, that I found myself emotionally overwhelmed as I started to pack my suitcase in our San Francisco hotel room on the last night of the trip.  Tears started streaming as I realized I didn't want to go back...not to Houston...but to the treatments.  After the emotional hit in June & July for having to slow down and take a break, I was suddenly not ready to start again.  And going home meant round 4 was starting soon.

Using the birth control in June, I timed my full natural cycle to end and the next to begin a day or two after arriving back in Houston.  At least this part of my system is consistently cooperative and predictable.  Although, I suppose my ovaries are indeed predictable...predictably uncooperative.  My new cycle started about 36 hours after we landed in Houston, which meant I needed to go in for a blood test and ultrasound to ensure all was well.  I cried that night.  I wasn't crying for the appointment, the estrogen, which was scheduled come a few weeks later and make me deeply nauseated, or the shots, which will come after the estrogen.  I cried because I'm afraid to get on the roller coaster again.  The tentative hope followed consistently by the awful disappointment.  I'm in self-preservation mode, and asking myself how I could possibly believe that this round will turn out any differently than the last ones.

When my acupuncturist asked how I was feeling this week, which is the week I'm due to start the estrogen, I described this stress and fear as the tears started again to roll.  I admitted that it's not helpful, but that it has been a lot more difficult to control this time.  Before the unanswered prayers, the miscarriages, and all this IVF ("Isn't Very Fair") business, I would have just thought I needed an attitude adjustment.  While that's not entirely wrong, at this point in the unforgiving process, an attitude adjustment is quite a bit harder than just blinking my eyes a few times, saying a few prayers, and suddenly seeing things differently.

So there I am, in my acupuncturist's office, and I can't keep the tears in.  I had intended to express some of these things, though quite a bit more professionally and gracefully than this...

Thankfully as you may recall, my acupuncturist primarily sees women facing fertility challenges.  I'm certainly not the first hormonally strung-out woman to break down during an appointment (if the super-sized box of kleenex on the table that changes out regularly is any indicator).  My acupuncturist was understanding and empathetic.  They even have coined a name for what I'm feeling...they call this the "Circle of Pain".  Very apt.  It goes something like this:

• When you do the same thing again and again, feeling the hurt each time, it's hard, if not impossible, not to expect it.  CHECK.
• You start telling yourself that chances are slim and it won't likely work.  CHECK.
• You start to prepare for and even grieve the disappointment that hasn't happened yet, and stress about the decision that comes after that.  DOUBLE CHECK.
• Ultimately, you feel miserable for the entire journey, whether or not it ends badly...

And now, you probably saw this coming, the case for optimism!  So thankfully, they aren't telling me to go out and skip through the daisies with excitement and certainty that round 4 will all be perfect.  Something in between.  I was given an exercise called "Positive Storytelling".  The gist is this:

• Write down (or tell yourself) your current view of it all, then, do it again, but with no fear, guilt, anger, or painful theme.  
• Visualize this revised version as best you can.  Even if it feels stupid, saccharine-y, and naive.  
• Rinse, lather, repeat daily.  

7 days in a row is apparently enough to help convince your unconscious brain that the story is better than it originally thought, and it will (hopefully) stop triggering the feeling of overwhelmed despair.  Even if your conscious brain is still concerned and fearful. SCIENCE!

I do believe that writing this blog has helped up to now, and maybe stepping back from it during the last couple of months has been somewhat counterproductive. Collecting my thoughts and explaining / documenting the process is, in fact, a way to try to look objectively the situation, try to make sense of my feelings (although maybe not completely without pain / fear), and hopefully find some humor in it all...

This "Positive Storytelling" is totally NOT new brain science...positive affirmations are built on the same principles, I suppose...