Stim Check 2

E2: 664pg/ml

Lining: 7mm

Follicles:

1. 11mm
2. 11mm
3. 10mm
4. 10mm
5. 10mm
6. 9mm
7. 9mm
8. 9mm
9. 8mm
10. 8mm
11. 8mm
12. 7mm
13. 5mm

Most of these follicles will be the same as the ones that were measured on Sunday, but some may be different, such as the new 5mm follicle.

The next stim check is on Thursday.

Choosing CCRM

This is the current home of our precious embryo, as it awaits us, cryopreserved and suspended in time. Soppy though it sounds, both of us were overcome with a strange and powerful feeling as we approached the CCRM building for the first time yesterday.

We chose CCRM based on a number of factors, though there were many things to like about our local clinic too. We loved our RE there, who is warm and chatty and just generally made us feel as though this was all definitely going to work. He also got to know us a great deal over the ten or eleven months he worked with us, as was succinctly and pointedly verbalised shortly before my frozen transfer in June, when, as I was leaving his office, he called after me “don’t worry, remember, I know your cervix very well”. And he did. I was worrying, because my cervix is a stubborn beast that tries to resist the insertion of a soft catheter containing embryos, which was almost certainly the reason for our unsuccessful first transfer.

My nurse there was also very entertaining. Shortly after we first started working with them and we were on our first (and last) month of the ovulation stimulating pill Clomid, she called to enquire as to whether we favoured an IUI that month (turkey baster) or whether we were going to try the old fashioned way first. She must have been in a terrible hurry because she chose to ask this, admittedly, simple question by barking down the phone “insemination or timed intercourse?”. Reminded of the “crucifixion or freedom” scene in Monty Python’s “Life of Brian”, I burst out laughing. For what it’s worth, we went with the latter.

But during my research over the months, I became aware of the incredible success rates at CCRM. In 2006 for women between 38 and 40, the live birth rate was 25.4% at my local clinic and 44.4% at CCRM. That’s a remarkable difference. CCRM’s success rates are unbeaten anywhere in the world, particularly for older women, and I started wondering what it was about them that made them so unbelievably successful. Following our devastating early miscarriage in June, we decided to book a phone consultation with the leading doctor there and it became immediately clear what their success was all about. Before the phone consultation could take place, we were asked to fill in a huge form listing every tiny detail of our medical history, particularly our history of infertility. The consultation itself gave us a great deal of confidence in our possible new doctor, especially when we heard about the intense “one-day-workup” they perform on every couple before they start treatments on anything. Off we went in August, to be poked, prodded, questioned and educated for a full day. As our results trickled in over the next couple of weeks, many previous mysteries fell into place for us and we knew that, if anyone could help us, it was CCRM. Unlike many other clinics that assume that it’s “just old age”, they left absolutely no stone unturned and even asked me to do some more tests locally to ensure my uterine lining was receptive to the successful implantation of an embryo, lest we find the “golden egg” and mess it all up with an unreceptive uterus. Luckily I passed those last tests.

An additional and extremely compelling push towards CCRM was the fact that, in collaboration with a laboratory in New Jersey, they perform a brand new type of genetic testing on five-day embryos (blastocysts). Now, we’d hitherto been uncomfortable with the concept of genetic testing, because it seemed somehow unethical and, without further investigation, smacked of “designer babies”. However, we’d learned that, coupled with ovarian reserve itself, meaning how many eggs a woman has left, the main reason for low pregnancy and high miscarriage rates in older women is a high occurrence in their embryos’ chromosomal defects. In fact, once you reach your late 30s and early 40s you can only expect about 15-20% of your embryos to be chromosomally normal and, hence, viable. This is because the eggs have been sitting around in the body since birth and the chromosomes have been stuck together for so long that they have difficulty separating, which they must do to reduce the number of chromosomes from forty six to twenty three. So, when combined with the man’s half, there's either one chromosome too many or one too few. In the vast majority of cases, this will lead to non-implantation, in some cases it will lead to implantation but loss of the pregnancy and in extremely rare cases it will lead to a child with birth defects that will only live for a few weeks. The exception is babies born with Down’s Syndrome – otherwise known as Trisomy 21, a third 21st chromosome.

Once we learned of the high number of chromosomally abnormal embryos we are likely to be producing each cycle and we’d already experienced a loss, we felt that genetic testing was a good way for us to move forward with a reduced risk of having to go through many more failed cycles or losses. At our age time is of the essence, not to mention our increasingly fragile emotional state and the heavy financial burden of repeated IVF cycles.

Traditionally available pre-implantation genetic screening (PGS) is performed on three-day embryos which are at the six to ten cell stage and can only be tested for nine of the twenty three chromosomes. Obviously taking one or two cells from an embryo that only has six to ten is a very risky matter, since you are removing a high percentage of the overall genetic material within that embryo. It has also been reported lately that this traditional method of genetic testing is not as accurate as once thought and can lead to both false negatives and positives.

By contrast, the new test looks at all twenty three chromosomes and is therefore much more comprehensive. What’s more, it’s performed on five-day embryos with sixty to one hundred cells so it’s a great deal less risky to remove a couple of cells. Since the latest an embryo can be transferred back into the woman’s body is five days after fertilisation and the cells are sent to a laboratory in New Jersey for testing, the embryos are vitrified (flash frozen) after the cells are removed and any embryos that tested normal are then transferred in a subsequent cycle. Although it’s difficult to wait, this has the advantage of giving the body a chance to rid itself of the high-powered stimulation medicines that were given during the retrieval cycle so it’s in a better position to successfully implant the embryo once it’s transferred.

The first baby tested in this way was born in June 2008 and so far 75-80% of transfers with two normal embryos have led to healthy, viable pregnancies. Currently there are only two centers that offer this test, but it’s thought that, ultimately, this method will change the way IVF is performed world-wide.

Having said all that, in the end it was this view from outside CCRM that clinched it for us.

Stim Check 1

E2: 255pg/ml

Uterine Lining: 6.5mm

The lining is expected to thicken up during a cycle so that it’s nice and plush for the embryo to burrow into, however for this cycle it doesn’t matter since we’re testing and freezing all our embryos, so there won’t be a transfer. It’s still good to know that my body is functioning normally, though. As a point of reference, my lining was 2.8mm at the suppression check last Monday.

Measurable Follicles:

1. 8mm
2. 8mm
3. 7mm
4. 7mm
5. 7mm
6. 7mm
7. 6mm
8. 6mm
9. 6mm
10. 6mm
11. 5mm
12. 5mm
13. 5mm

Each follicle is expected to grow by 1-2mm per day and can be classed as mature between about 16mm and 22mm. As I’ve mentioned before, the important thing is that as many as possible are in the mature range. At this point, I have alot in very close proximity, so that’s a good thing. Also encouraging is the fact that on this day during my last cycle I only had four measurable follicles. We think we’re off to a good start but we know from experience not to get excited about anything, because things can go dramatically wrong at any time. Though quantity is excellent, it’s the quality that leads to a healthy baby and we’ll have to wait a couple of weeks to find out how strong the fertilised eggs are and several more weeks to find out whether they are viable.

The next stim check is on Tuesday morning.

Destination Denver

We’re in Denver! We arrived at about 5pm yesterday afternoon after 22 hours of driving on 1402.5 miles of road. We passed through Georgia, Tennessee, Kentucky, Illinois, Missouri, Kansas and Colorado, crossing the major rivers Tennessee, Ohio, Mississippi and Missouri in the process. As we passed under the St Louis Arch, we were amazed to see large chunks of ice in the Mississippi.

We drove on one single interstate, I70, for a total of 583.4 miles. Crossing Kansas was probably the most interesting part. We saw wide open space for miles and miles, dotted with huge windmill farms, many little oil derricks which neither of us expected to see in Kansas, small family farms, huge industrial farms, tiny “towns”, all with their own church, where the economy was clearly centered around using, producing or repairing farming equipment. We were violently attacked by tumbleweeds rolling across I70 – in some cases the whole road was filled with them and we had no choice but to drive straight through, feeling them smacking against the car and, in one case, getting stuck on the grill for a few miles. We knew for certain that we were in the middle of absolutely nowhere when we saw a sign at the side of the interstate informing us that the next Starbucks was a mere 70 miles up the road. It must be the only Starbucks in a 200 mile radius.

Weather-wise we couldn’t have been luckier. We had bright sunshine for the whole drive, except for a bit of drizzle in Kansas City. We kept seeing huge black clouds and storminess to our North but never actually went into it. That’s particularly amazing, considering today there are major storms crossing through the Midwest.

Unfortunately we also experienced the first crisis of this cycle. Yes, indeed, I spoke too soon in my last post, too confident by far. I should’ve known better.

Some of our medicines need to be kept refrigerated, others at room temperature. I had bought a small beer can cooler for the refrigerated medicines and put some ice packs in with them, so that was fine. The room temperature drugs were in a bag on the back seat of the car, so that we could easily access them when it was time to pull over and administer them. However, probably about four hours before the end of that day’s drive we’d moved some things around and the bag must have tipped between the seats, because when we got to the hotel, the boxes were warm from the car heating blowing up from under the front seat. Since they need to be stored at no more than 77°F we were sure we’d over-heated and ruined them. Being Christmas night, we couldn’t call the pharmacy about it, so our evening took a complete nose dive, to say the least. Our carefully laid plans for Christmas dinner at the International House of Pancakes in Independence, Missouri, were blown apart, because neither of us felt like eating. The reason we’d carefully selected the IHOP was, at least in part, because it was the only place open in the whole of Independence on Christmas night. In fact, we hadn’t factored in the food situation on Christmas Day. I had made my own food for the lunches since there are only a few things I can eat (that’s for another post), but poor J the Elder started looking for some lunch, anything at all, from 11.30am onwards and we finally pulled into an open Hardees (yum yum) at 2pm. But I digress.

We knew the pharmacy from which we purchased the drugs opened at 8am eastern time. During the night, I had, at least partially, regained my ability to form normal, even logical thought processes and had thought about the fact that the drugs are shipped to me in a cardboard box with no refrigeration, even in the summer in Atlanta. If they were that sensitive, surely the pharmacy wouldn’t risk the likely scenario that they’d sit in a Fedex delivery van for several hours at 95°F? So when I called the pharmacist at exactly 7.02am central time (I thought I’d give her some time to take her coat off), she confirmed that all was well and, indeed, not only do they send the drugs out by Fedex overnight delivery unrefrigerated in summer and winter, but they actually receive them from the manufacturer unrefrigerated by ground transportation, any time of the year. The storage instructions are for people who think it might be a good idea to store the drugs in their garage for several months in the height of summer. What a huge relief; I can’t even tell you how happy we both were to hear that. Of course we were extremely careful, bordering on paranoid, on the second day of the drive. Now we’re here, all our meds are in their own unique and highly controlled environments.

Our first stim check is tomorrow morning!

Still Life

Here’s a still life of our bottle of red wine and tumble in the hay equivalent for the creation of new life. These are the different medicines I’ll be injecting or ingesting over the next 12 days or so, along with the syringes, gauze pads and alcohol wipes.

I’m safe in the knowledge that it can only go better than our last cycle in October, which started off with J the Elder accidentally piercing a blood vessel in my thigh, causing blood to spurt out in both directions, by which I mean externally and internally. The resulting large, bumpy bruise had me explaining the mishap to each and every ultrasound tech, nurse and doctor I was seen by (and there were many of them) lest they call social services and arrest my dearly beloved for domestic abuse. I did get the nagging feeling that my explanations were backfiring in the manner of “methinks the lady protesteth too much”, but whatever the case may be, mercifully J the Elder was not taken in for questioning. More traumatising still, and by a wide margin, was the unfortunate incident with the very last of our big gun evening shots. In an, as it would quickly turn out, extremely vain attempt to suck every last drop of medicine out of our very last, no-backup-whatsoever vial, we managed to pull the plunger back so far that it came out. We were then forced to watch in utter horror as half of the liquid intended to give my follicles one final boost to maturity dripped onto the floor of our hotel room and the other half dribbled up J the Elder’s arm. There were many reasons to panic about this: the two most prominent were that it was after hours and all the pharmacies were closed (and, even if we found one open, we had no prescription) and that the shot had to be administered at the same time every night. We’d spent a large proportion of our possible child’s college education to get to this point and it might now be ruined. Oh and each shot retails for the princely sum of $240. Anyway, we called the out-of-hours line at CCRM and, by some incredible fluke, the on-call nurse that night was my very own nurse, who made a U-turn from her way to dinner with her husband back to the clinic, met us there and gave me the shot herself. We learned that they have an arrangement with a local pharmacy to keep a consignment stock of medicines there that you later pay the pharmacy for. When all was said and done, I got my shot only thirty minutes after I should have and all was well. So my confidence in a comparatively more successful administration of my injections this cycle is pretty solid. Famous last words………

There are three different drugs to be injected. Lupron twice per day every 12 hours, Menopur in the mornings and Gonal-F in the evenings. Lupron goes in the thighs and the others in the stomach.

Lupron is used to switch off communication between the pituitary gland and the ovaries so that the body doesn’t pop out the eggs on its own before they can be professionally retrieved. It’s very hard not to worry that the message to hold on to the eggs won’t get through to my ovaries, they will first rejoice in all the unusual action and then burst forth, releasing a crop of carefully and lovingly nurtured eggs into the wild. I will let you know when we reach the stage that this particular concern is at an all-time high.

Menopur, a so-called stimulation drug, is a mixture between two hormones, follicle stimulating hormone (FSH) and luteinising hormone (LH). FSH has the self-explanatory role of making the follicles grow; women make it naturally but the doses I’ll be getting are super-sized. LH is the hormone that tells the body to go ahead and ovulate – so, given what I just said about the Lupron, there are some conflicting messages for the body to grapple with.

Gonal-F, also a stimulation drug, is pure FSH. Some RE’s prescribe only FSH and others, such as mine, prescribe FSH and the FSH/LH combination.

In an interesting side note, between the ’60s and late ‘90s the only products available for stimulating the ovaries were derived from the urine of menopausal women, usually nuns in convents, who peed into vats or brought huge jugs of urine to factories to be processed and purified. I kid you not.

So I started the Lupron injections yesterday and will add the stims tomorrow as we begin our drive to Denver. We’re particularly looking forward to mixing and administering the Menopur shot in the car, probably somewhere near Nashville, TN, where will be at the time it needs to be given. I wonder whether I should get CCRM to fax me a letter explaining the pressing purpose of my drug-use in broad daylight at the side of the road, in case we have an encounter with the Nashville Police Department.

Happy Holidays!

Pass!

I had my first of many rendezvous with the trusty ultrasound wand (crudely nicknamed dildo-cam) and a small, flimsy paper rectangle whose - clearly misguided - vocation was to cover up my modesty as I make idle small talk with the ultrasound tech about her forthcoming holiday plans and other diversions. The stirrups and, may I say, disgusting stirrup covers were also present. I kept my socks on. I also had my first blood draw. During this cycle I estimate that I will have ten or eleven such encounters before it’s decided that my eggs are ready to be retrieved. This first one took place at the local RE’s office, but all the rest will be in Denver. Our local RE was very gracious when we came clean in July about our plans to defect to the competition. He actually told us that he was more concerned with our success than his being the one to “get you pregnant”. This makes things alot less awkward on days like today when we needed their services. They faxed the results of my ultrasound and bloodwork to CCRM. CCRM then called me to let me know that we have the go-ahead to move forward with the cycle. Phew, good news.

The purpose of the suppression check is to look for any cysts that may interfere with follicle stimulation (each follicle generally contains an egg) and to measure the level of E2 (estradiol) in the blood to make sure the baseline is low at this point (they want it below 50). They also count the antral follicles visible in the ovaries.

As for cysts, my two resident endometriomas (chocolate cysts) are still hanging out in my ovaries, as expected. They’ve both shrunk by a couple of millimeters. But there are no active cysts lurking in there, so that’s good news. An active cyst would generate E2 of its own, expressed by a level greater than 50 at this point in the cycle, and could basically interfere with the stimulation of the follicles by stealing the hormones for itself and leaving none for them to gorge on.

E2 is the hormone that rises as the follicles grow – each mature follicle generates about 150-200pg/ml. E2 levels need to be carefully monitored to ensure there’s no risk of hyper-stimulation which is a condition that would, after one ER (egg retrieval), swiftly land you in the other ER (emergency room); that’s if your cycle wasn’t cancelled before egg retrieval. You’re getting into the danger zone if your E2 starts to move towards 5000pg/ml. Mine was less than 20 today, pre-stims. They’ll use this number as a baseline from which to measure my follicle growth.

And my antral follicle count (AFC) was good today. The AFC is always the most fear-inducing part for me, because antral follicles are an indication of ovarian reserve, in other words of how many eggs you have left before menopause sets in. Each woman is born will all the eggs she will ever have and as a teenager she has approximately three or four hundred thousand of them. From then on, about a thousand eggs die off each month. As we age, not only do we have fewer and fewer of them left, but their quality declines sharply as well. Antral follicles are those follicles that are resting in the ovaries at any one time, of which, in a natural cycle, one will become dominant and ovulate but which, in a medicated cycle, can all be stimulated for possible retrieval and fertilisation. The “trick” here is to try to get as many of them as possible within the mature range at retrieval. Some may be too small to be mature and others may be allowed to become post-mature if there’s the potential for more smaller ones to become mature instead. Only mature eggs will fertilise. In the end, it’s a numbers game. We will lose some along each step of the way so the more you start with, the better. I might add that quality is always better than quantity.

So this was the first hurdle with more hurdles to come: Will I respond well to the stim drugs, meaning will my follicles grow nicely, will my E2 show a steady increase, will I have enough follicles around the same size, how many will be retrieved, how many will be mature, how many will fertilise normally, how many will stick around and develop into 5-day blastocysts (they need to be at that stage to be biopsied) and, finally, most importantly, how many will the tests reveal to be viable? A cycle can take a turn for the horrible at any time and be cancelled. We’re holding on to our hats. The first shots start tomorrow morning.

Why Blog?

Um, as I sit here writing my first ever blog entry, I'm still feeling quite unsure about this blogging thing. I've been thinking about doing it for a while and, with our third and final IVF cycle fast approaching, it's now or never... There are a few things that are making me squirm about doing this. First, the vanity factor. I mean, it does seem awfully self-important to think that my daily life might be interesting enough for someone to actually take the time to read about. The second, and very significant squirm factor is the personal nature of the subject matter, infertility. If I am to give an honest account of the unsavoury happenings, then there will be mention of vaginas (well, mainly mine), sperm, hideous instruments and procedures that generally involve padded stirrups (some also involve dark rooms with plastic cups and DVDs) and raw emotions (I will make every attempt to spare you those); you get the picture. It's just plain embarrassing, or at least it was before we started on this bizarre journey. Now I worry that I'm too unfazed by it all, and that what seems like a perfectly normal subject of conversation to me, is excruciatingly embarrassing for the other party. Hmmm.

Having said all that, our close friends and family do like to know what's going on and this is a way of communicating to everybody, just about in real time. And, from a selfish point of view, this may (or may not) be a way of keeping me/us a bit more grounded and of maintaining perspective. It might help to write things down as a way of releasing some of the tension. I'll get back to you on that one when we're in the process and I know if it's helping. Thirdly, I'm hoping that this blog will be an interesting record of our cycle. After all, it'll involve new and cutting edge technology for pre-implantation embryo testing, which is only performed in two clinics world-wide (both in the USA). The first embryos were tested using this method in 2007. There are still very few couples that have gone through this procedure and the first baby tested in this way was born as recently as June 2008. So it's somewhat revolutionary and we're part of it. Exciting.

Weighing it all up, I'm going for it. Wheeeeeeee. Perhaps I'll get more comfortable with it later on, but for now I'm not going to be identifying who we are with photos or names, just keeping it anonymous. And we'll only share the link with our families and a few friends who know what we're doing and have supported us in this process. Next step: click "publish post". Here we go......