Sunday, January 25, 2009

Unhealthy Living

I haven’t had time to blog. I’ve been too busy making up for a year of consumptive abstinence by gorging on treat after delicious and unhealthy treat. On Sunday, the eve of our first anniversary, J the Elder impressed me to no end by disappearing into the kitchen after dinner and emerging twenty minutes later with Nutella crepes he’d just made. I showed immense restraint by having just three of them. On our anniversary the next day we went to our favourite sushi restaurant for dinner. It just so happens that there’s a Krispy Kreme right next door to it and it seemed like a splendid idea to get in line at the drive-through (why do they make it so easy?) and pick up one or two small doughnuts on the way home (well, four actually). On Tuesday I was back at work in my office at home when there was a knock on the door and a nice man from UPS handed over a box containing nine cupcakes, sent from California to our door by a friend of J the Elder’s who lives in Oklahoma and had lost a bet with J over the outcome of the Florida/Oklahoma championship game. Since there was a three-day freshness guarantee, we were obliged to consume these cupcakes by Friday and did so very stoically and without grumbling, ending our dinner with them every evening from Tuesday to Friday. Does putting on running clothes count? If it does, I did get a great workout yesterday without ever going outside or breaking into a sweat. I did intend to run, but it just didn’t seem to happen. Then last night we went out to meet an old colleague and friend of mine from Australia who was in town on business. It would’ve been extremely rude of me not to have those four vodka and cranberry juice drinks. I’ve often heard that the early pregnancy feeling is very similar to a hangover. If that really is so, I feel pregnant this morning. Very pregnant.

We had a telephone regroup with the doctor at CCRM earlier this week. Unfortunately it didn’t have the desired effect of making us feel any better. We were given a 35-40% chance of a successful pregnancy if we only have the one existing normal embryo from last cycle to transfer. Those don’t seem like very good odds, after all we’ve done to get to this point. Obviously we’re still trying to be hopeful about the three embryos that are being tested from this cycle, but it remains difficult to be too hopeful. The dilemma now is whether, if we don’t get another normal embryo to transfer, we should go ahead and transfer the one we have or whether we should somehow try to do another cycle, locally or at CCRM. It’s not only about increasing our chances of getting pregnant with one healthy baby with the transfer of two embryos. At this point we’ve got nothing and we don’t want to be greedy, but strategically, if we think we’d want to do another cycle for a sibling after one baby was born, then it would be much better to retrieve eggs now than next year.

It’s not immediately clear how we would afford a fourth out-of-pocket cycle, but if we could and went back to Denver, CCRM wouldn’t put me on birth control pills again, because of my Protein S deficiency and the resulting risk of blood clotting. They would also try Gonal-F only, rather than a combination of Gonal-F and Menopur. I did far better locally without birth control pills and without Menopur. In terms of protocol, they would either use Long Lupron again, or Antagonist. I need to read up on the Antagonist protocol before I can form a preference. The doctor didn’t seem to push one over the other and I’d always rather see a clear choice, since it would just make me feel as though the solution is obvious, rather than this being the Russian Roulette it really is.

If we decided to do another local cycle, it would cost us somewhat less, mostly in travel and hotel costs, but we wouldn’t be able to do CGH or microarray testing of all 23 chromosomes, because the local clinic doesn’t offer it. Instead we’d ask for a five-day biopsy and traditional PGS (pre-implantation genetic screening) on the blasts, to at least test for nine chromosomes. Usually this test is done on three-day embryos and then the normal ones are transferred two days later, but we wouldn’t want to put our three-day embryos through that, since they only have six to ten cells at that point and by taking out one or two of those cells for testing, you’re removing a high percentage of their genetic material. Also, it’s recently been reported that there are many false positives with this technique, meaning that some embryos might test positive for chromosomal abnormalities, but are, in fact, normal. Doing a five-day biopsy would mean vitrifying the embryos and transferring them in a subsequent cycle, which, while adding more time, does have the advantage of the body getting rid of all the stimulation drugs. If we did the local cycle, we’d probably arrange for any normal embryo/s to be shipped to CCRM so that we’d be able to transfer two together.

Of course this discussion is entirely academic until we get our results, because if we do have one more normal embryo, we’ll transfer the two at the earliest opportunity. However, as anyone who is going through fertility treatments knows, it helps to have a plan in place so that you’re not floundering and too upset to make a well thought-out decision should bad news come in.

Saturday, January 17, 2009

From The Frozen Tundra That Is Atlanta, Georgia

As I write this, I’m sitting in our office wearing Ugg boots, a red puffer jacket (yes, very 80s) and a woolly scarf. No gloves. I should hastily clarify by saying that I’m wearing these items in addition to my normal clothes. It just had to be the coldest weekend in the past year for the heat to go out on our ground floor and in the basement. Luckily, the upstairs furnace is still working but the cold downstairs is starting to affect the temperature upstairs, too. For reference, it was 71°F (21°C) upstairs this morning and a very refreshing 46°F (7°C ) downstairs. We’re off work for MLK Day on Monday, which is also our first wedding anniversary, and we’ll be spending it freezing in the morning and in the company of a nice technician called Antonio in the afternoon. Antonio promises that warmth will be restored by Monday evening.

Having spent the week since we heard the news about our three blasts in a state of utter doom and gloom, I’m starting to feel a bit better now. If I really try, I can be quite good at doom and gloom. Here’s how CCRM very accurately summarises the emotional impact of infertility:

• feelings of loss of control are common and sometimes uncomfortable
• the emotional roller coaster of hope and despair, either with each treatment or on a monthly basis
• feelings of failure and low self-esteem are normal as are feelings of guilt, blame, shame and embarrassment
• the process erodes and consumes time and energy
• financial issues - loss of other dreams in exchange for treatment
• changes within your relationship - pull together or apart - infertility brings most couples closer together but changes in intimacy are often associated with treatment regimens
• impact on employment and performance at work
• feelings of injustice are reality based

We know we’re old and trying to beat the odds, so I do sometimes wonder why we’re even expecting this to work, but we’re still convinced it will work for us soon. I’m mainly feeling better because, as drummed into me by my wonderful, less doomy and gloomy DH, we already have one viable embryo waiting for us; and not only because of that basic fact alone, but also because it means that we can produce them generally. Statistically we really ought to have one more normal embryo in the new batch, but with just three it’s hard to count on the stats. We decided to organise a phone regroup with the doctor this coming week to get his view on the cycle and any ideas he might have on improving our blast development, in the unlikely event we were able to do another cycle. We’re aware of the possibility that he’ll simply put it down to age; he did tell us before egg retrieval that I was doing spectacularly for my age, but I suspect it may just not have extended to blast development.

I’ve been going over the differences between our local cycle (seven blasts from ten embryos) and our CCRM cycles (four and now three blasts from two sets of eleven embryos). Other than several months between them and, therefore, just older eggs, the two major differences were that the local protocol didn’t include birth control pills and that we only used Gonal-F to stim, rather than a combination of Gonal-F and Menopur. Perhaps my eggs just don’t like Menopur. In the end, it’s hard to pinpoint it with so many variables at play, but talking to the doctor may give us more perspective.

Tuesday, January 13, 2009

Day Six Report

Unfortunately our hopes for more blasts than last time were dashed today. In fact, we’ve ended up with fewer. The embryologist called to let us know that only three of the nine good-looking embryos developed to the blastocyst stage. One of them was biopsied and vitrified (flash frozen) yesterday at day five and the other two today because they took longer to develop into blasts. Their grades are as follows:

1. 4BA
2. 4BB
3. 3BB

The number refers to the stage of blast development, 3 being a full blastocyst and 4 an expanded blastocyst – I was told that this is not as important as the letters. The first letter refers to the cells that will become the embryo and the second letter to the cells that will form into the placenta. The embryologist told me that the 4BA embryo is near-perfect and the BBs are very decent quality. Our one chromosomally normal embryo from last cycle is a 4AB, also close to perfect. However, the embryo quality has nothing to do with their chromosomal make-up, which is what we’re testing for. A perfectly graded embryo can be abnormal and very often is. It’s the embryo grade, combined with its chromosomal viability that leads to success, so long as the uterus is also receptive. We know the grades, but we must now wait two months to find out if any of them are chromosomally viable.

Needless to say, we’re extremely upset by this news. While things could always be worse and we could have had even fewer or, heaven forbid, none at all, this leaves us with an agonisingly long and terrifying wait for our results from the biopsies. The statistics for our age group leave us with, at most, one normal embryo to hope for. However, we know that it’s touch and go whether there’s a normal one among them. Last time we had one normal embryo among four blasts. At this point, we’d be over the moon with one normal in this group of three, because that would give us two embryos in total to transfer together sometime in late March or so. Transferring two would significantly increase our chances of one implanting and developing into a healthy baby.

How we’ve developed this problem of growing embryos to blast, I just don’t know. In our local cycle last March, we had seven blasts out of ten fertilised embryos, a much higher percentage. Of course, that cycle didn’t result in a healthy pregnancy so we can’t class it as a success. Our fresh transfer failed because of a mechanical issue at transfer and the frozen one ended in miscarriage. We didn’t have the embryos tested so we have no idea how many of the seven were chromosomally normal. CCRM are stricter about the quality of blasts, but the seven we had locally were of a decent quality and would most likely have passed at CCRM as well. Since the laboratories at CCRM are known to be fantastic, this situation is even more of a mystery to us. CCRM expect about 50% of fertilised embryos to grow to the blast stage and this should have given us five or six. We have to face the fact that our ages are really going against us and that this could be a contributing factor, even between last March and now. Mercifully my ovarian reserve, meaning the number of eggs still remaining, is far above average for my age group, so at least we start with a lot of eggs. Thank goodness for that, since otherwise we really may have had none at all to biopsy. But to go from twenty one eggs retrieved to just three blasts is a devastating blow.

Saturday, January 10, 2009

Day Three Report

Our Day Three Report is in. Of the eleven embryos that fertilised normally, all are still hanging in there, but nine of them are within the range of cells they like to see at this point. Three-day embryos should contain between six and ten cells, eight being ideal. Here's the breakdown:

2 at 10 cells
4 at 8 cells
2 at 7 cells
1 at 6 cells
2 at 4 cells

The four-cell embryos haven't reached the appropriate milestone for three days, so they only have a 15% chance of developing further. The other nine, on top of being within the necessary range, also have very little fragmentation, which is positive.

I asked for a comparison of last cycle's embryos; according to the embryologist, it looks as though these ones are slightly better, both on cell-count and quality, but we really just don't know how well they'll continue to grow. Anything could happen between now and Monday/Tuesday. We'll get the big call on Tuesday with news of how many made it to the blastocyst stage and were biopsied. A blast contains between sixty and one hundred cells. CCRM wait until Day Six to call because some embryos take six days, rather than five, to develop into blasts. The agonising wait continues, but we're happy with today's report.

Thanks to everyone for their lovely comments and for sending good vibes to our hard-working embies. Please keep the vibes coming.....

Thursday, January 8, 2009

Déja Vu

We got our fertilisation report this morning. In a very strange twist, we have exactly the same numbers as last cycle: Fifteen eggs were mature and eleven of them fertilised. Three of the fifteen didn't fertilise normally because they didn't have enough DNA and one didn't survive the ICSI procedure. We were hoping for a few more this time and on this different protocol, but the more important result is how many of the eleven develop into five day blastocysts. Last time, only four of eleven survived to that stage. We're hoping that we can get a few more this time since, statistically, only 25% or so of the blastocysts will end up being genetically normal.

We'll get the next update on Saturday to tell us how many of the eleven have made it to the three day, six to ten cell stage successfully. It would be a gross understatement to call this a nail biter, but you get the picture.

We're now more than half way home, having arrived in Fort Smith, Arkansas for the night.

Wednesday, January 7, 2009

Lucky Number 21

Our lucky number is 21. That’s how many eggs were plucked from my ovaries this morning. It all went well and I don’t think I disgraced myself by swearing under anesthesia or thrashing around and hitting the closest person leaning over me when I woke up (this happened when I woke up from surgery in 1994 and I kicked and hit the anesthesiologist, who, embarrassingly, also happened to be the mother of one of my work colleagues). I was also very graceful when presented with my ginger ale and crackers, consuming them in a very measured fashion.

Our team of 21 were going to be allowed to hang out for a few hours in the dish before being manually injected with J the Elder’s sperm in a delicate procedure called ICSI (intracytroplasmic sperm injection). The total count was 86 million sperm, of which 50% were motile, which basically means they swim in a straight direction instead of staggering round and round in circles as if in a drunken stupor. 50% is what they like to see so we’re very pleased. This means that the embryologist has the enviable task of selecting 21 tip-top-looking sperm from a pool of 43 million. I have visions of them still sitting there now, at 9pm, trawling through them all and carefully selecting those that are not two-headed, tail-less or otherwise aesthetically and reproductively challenged. In reality, they were going to perform ICSI this afternoon, at about the time we were driving past CCRM on our way home. As we spotted CCRM from the interstate, we cheered on our brand-new embryos from the sidelines, shamelessly bribing them with promises of everlasting unconditional love, toys galore, lovely trips to Europe, fabulous grandparents, aunts and uncles and very cool older cousins on both sides of the Atlantic. Surely these incentives will be too compelling for them not to develop into super-embryos.

We will get a call from one of the embryologists tomorrow morning, telling us how many eggs were mature and how many then fertilised normally. Waiting for this call, and the subsequent two calls this coming week, is worse than waiting for calls from new dates, schools and universities with exam results and companies with job interview news all put together.

Other than some pretty severe abdominal pains, for which I’m taking pain killers, and some fatigue, I’m feeling good after the surgery and we’re looking forward to making our way home over the next two days. We made it to Raton, New Mexico tonight, which has shaved about four hours off our twenty four hour journey.

Tuesday, January 6, 2009

Goodbye Weird Diet, Hello Krispy Kreme

Back in the days when I thought I was pregnant every month and I was in complete denial over the possible need for major medical intervention, I started looking into some natural ways of boosting my ovarian reserve and, in particular, my egg quality. I read Randine Lewis’ book “The Infertility Cure” practically in one sitting and decided to do a series of three phone consultations with her group. Based on their diagnosis – which, to be fair, other than a couple of minor imbalances, was mainly advanced maternal age, but a definitive diagnosis nonetheless - I started introducing Chinese herbs, acupuncture and their recommended diet for my case. Little did I know that I’d be pursuing these recommendations for an entire year. Here’s the advice I’ve been following since last January:

• Specially formulated chinese herbs, twice daily
• Acupuncture every other week, and weekly leading up to and during an IVF cycle
• A diet devoid of sugar, wheat and dairy products
• No caffeine
• No alcohol six weeks leading up to and during an IVF cycle
• Wheatgrass shots
• Supplements: Fish oils, wobenzyme, royal jelly, pre-natals, baby aspirin
• Femoral massage
• Qi Gong breathing exercises
• Daily meditation
• No running (that’s been particularly hard)
• No anti-histamines or pain killers other than Tylenol

Now, if you’d told me a few years ago I’d be denying myself many of the things I love (eating, red wine, the occasional cocktail, running), I would never have believed I had it in me to show such willpower. Not in a million years. It’s incredible what you’ll do when you really want something.

J the Elder’s daily cocktail of supplements and no-nos consists of the following:

• Vitamin C
• Vitamin E
• Multi-vitamin for men
• Zinc
• B12
• L-Carnitine
• Grape seed extract
• No hot tubs or baths
• No anti-histamines or any pain killers other than Tylenol
• No working out or running during an IVF cycle (as instructed by CCRM)
• No caffeine leading up to and during an IVF cycle (including chocolate)
• No alcohol during an IVF cycle

He’s been fantastic about following these guidelines, too.

Who really knows what helps but, given the choice, we’d rather be safe than sorry. And if any of these things just boost our chances by the smallest margin, they’re worth it.

So, given that this is our last cycle and we now have a couple of months to wait until the embryo transfer, I’ll be able to go back to normal food and drink starting tomorrow, at least for a while. This has been a major source of excitement for me for some considerable time. Here are some of the things I seem to be craving:

1. Apple pie from The Treehouse in Peachtree Hills (no ice cream with it though)
2. A one-pump soy chai from Starbucks
3. Just one doughnut from Krispy Kreme
4. Bread, bread and more bread
5. Lashings of butter on my baked potato
6. Smoothies
7. Macaroni and cheese (huh?)
8. Burritos with sour cream and cheese
9. Quiche, any style at all
10. Neuhaus dark chocolate pyramids from Belgium (can anyone tell me how I can get my hands on them in Atlanta?)
11. Cooking and baking proper food for us, with flour, cheese, butter and sugar; what a concept
12. Red wine
13. Margaritas (must be consumed with Jill and Amy)

At the last egg retrieval with CCRM I distinguished myself by downing in one the can of ginger ale the nice nurse gave me when I woke up (probably slurping as well) and shoveling the entire plate of crackers that was handed to me in my mouth in the space of about ten seconds. I foresee a similar scenario tomorrow morning. At least they’ll expect it now.

Monday, January 5, 2009


Well, the stim part of the cycle has reached a somewhat surprising rousing crescendo. I met with the doctor this morning for a regroup. He thought we'd be triggering tomorrow for a Thursday retrieval, but he must have decided I was ripe for the picking after seeing my bloodwork numbers this afternoon, because I got the call from the nurse to tell us that we trigger tonight. The trigger shot is the culmination of all the shots. It basically sends a message to the ovaries to release the eggs 36 hours later and the retrieval happens an hour before that. This shot is not for the faint-hearted. It's an intra-muscular injection in the hip with a one and a quarter inch needle. Mixing it adds another interesting dimension, too. I was hoping to have a target drawn by my nurse for J the Elder to aim for as we did last time, but the timing caught us by surprise; we know where to aim. We must do the shot at exactly 11pm tonight, because the surgery is planned for 10am on Wednesday.

For the record, my stress levels at this point are at their highest so far in the cycle. On top of the trigger shot, which weighs on your mind until it's done, I'm wondering if my hormone levels are correct, whether my egg quality is good, how many will fertilise normally and will then go on to the next levels. This next part is going to be the hardest for us. Luckily J the Elder is his usual wonderful, calm and confident self.

I'll go in tomorrow morning for bloodwork to see if the HCG in the trigger injection was absorbed correctly and the levels look good. Otherwise, tomorrow is shot-free.

Sunday, January 4, 2009

Stim Check 6

E2: 3308pg/ml

Lining: where it needs to be so no exact measurement


These were the ones measured today:

1. 18mm
2. 16mm
3. 16mm
4. 16mm
5. 16mm
6. 16mm
7. 15mm
8. 14mm
9. 13mm
10. 12mm
11. 12mm
12. 12mm
13. 8mm

These aren't necessarily all the sames ones that were measured before, but at this stage they look for an idea of the largest, smallest and the clusters in between.

After chasing around various addresses in Denver trying to score the Gonal F yesterday and then ending up with an abundance of it, it was decided today that I'm to hold off on that particular shot entirely tonight (and I assume thereafter). Oh the irony! Basically I'm coasting now without the evening stim shot, but I'm still doing the half-dose of the morning shot. They want me to proceed slowly with my follicle growth to ensure the smaller ones can catch up without my E2 getting out of control. We're wondering whether the retrieval will be on Friday now.

My next stim check is tomorrow morning.

Saturday, January 3, 2009

Stim Check 5

E2: 2763pg/ml

Lining: didn't get an exact measurement today, but over 9mm


They measured 13 again today, the biggest at 16mm and the smallest at 9mm. They don't seem to be growing very fast, but I understand that's not necessarily a bad thing. Luckily my E2 went back to rising steadily following the big jump and subsequent reduction in the doses. I'm on the same lower doses tonight and tomorrow morning. It's a balance between keeping my E2 at an acceptable level (not too high) and helping my follicles grow.

This is the stage that seems to drag on a bit, waiting for the go-ahead for the mother of all shots, the trigger. The retrieval will be exactly 35 hours after the trigger shot. We keep speculating about when it will be, mainly because it's hard to estimate how many more doses of medication we need to get, but we just need to wait and see. Now it looks like the earliest day for retrieval is Wednesday and it may go out to Thursday. We might get a better idea after tomorrow's stim check.

Today our thumb twiddling was interrupted with some considerable "excitement" (read stress) when, after several long phone calls to Fedex, we found out that the drugs we had ordered from the usual mail-order pharmacy to get us through the weekend were not in fact going to be delivered by noon as arranged, because they were still in Memphis, TN. We were told that the likelihood of their getting to us today (and obviously tomorrow) was slim to non-existent. Brilliant! We were told this at 12.05pm and knew the local pharmacy closed at 12.30pm, so we dashed over there and bought enough Gonal F to get us through to Monday (luckily they had a prescription on file). The big negative associated with this situation is that it comes in the same format we spectacularly failed to administer successfully last cycle, namely the small vial with the large mixing needle, very full syringe and easy-to-pull-out plunger.

Of course, no sooner had we got back to the hotel with our stash of drugs, than Fedex called to inform us that our package with the dreamy Gonal F pen was in fact not really still in Memphis, but in a depot in Denver and did we want to pick it up, because it wouldn't be delivered today. Now we've gone from no supplies at all to having Gonal F coming out of our ears. Since it looks like we may need all of it, no worries there.

My next stim check is tomorrow morning.

Friday, January 2, 2009

Stim Check 4

E2: 2301pg/ml

Lining: 9mm

They only measured a few follies today and it was a different ultrasound tech. It's a bit confusing, so no list today.

My E2 really jumped overnight, so I've been told to halve the stim doses tonight and tomorrow morning. Since the largest follicles are not quite mature yet, and the smaller ones are still some way off, the high E2 number may mean that there are quite a few follies this time. The proof's in the pudding, though, and we'll have to wait until retrieval day to find out definitively how many there are.

My next stim check is tomorrow morning.

Thursday, January 1, 2009

Stim Check 3

E2: 1106pg/ml

Lining: 8.5mm


I was told that, at this stage, they measure the biggest five on either side, so I only have ten measurements today.

1. 15mm
2. 14mm
3. 13mm
4. 13mm
5. 12mm
6. 12mm
7. 12mm
8. 12mm
9. 11mm
10. 10mm

From now on, I'll be going in for a stim check every morning. At this point it looks like my retrieval might be on Tuesday or Wednesday.