Flotsam

I am endeavoring to type this while flat on my back, keyboard near my chin, so please forgive any errors.

This afternoon we transfered two embryos: one a 7-cell, one a 9-cell.

I was under the impression that even, rather than odd, numbers of cells are to be preferred, but I shan’t quibble. Both were grade two—our clinic grades from one to four, with one being the highest. The remaining 15 embryos will be watched for two days and any suitable specimens frozen. My clinic freezes only grade one or grade two embryos, and we transferred our two best, so we shall see.
The transfer itself was somewhat painful, involving multiple catheter changes and causing quite a bit of excitement. Once again my anatomy elicits consternation and awe among medical professionals: apparently there is a right angle in my uterus, forming part of a “C” shape around which the catheter had to be threaded. Dr. Bowtie, with his vaginal-spelunking headlamp on, eagerly called the medical student over for a look, pronouncing my uterus and cervix “unusual,” which I believe is a synonym for “moderately deformed.” So yes, the transfer was uncomfortable, and I am even now quite crampy, which of course sent me into paroxysms of despair because of articles like this.

For now I am relaxing and plying my potential progeny with macaroni and cheese and intramuscular shots of progesterone. My betas are scheduled for next Wednesday and next Friday, but I will not get the results until after the second draw. Of course I plan to start testing at home absurdly early (probably Sunday) in order to watch the trigger disappear and see if anything takes its place, because I have always preferred the slow dwindling of hope to the dramatic and devastating reveal. And of course, it might be positive, and I’ll gnaw off my own right breast (quite a feat, really) before I wait ten whole days for the lab techs to give me the news.

Our clinic does not give out pictures of the embryos transfered, but they do usher you into the lab to look at them under a microscope, and I say this, I promise, with scientific dispassion: our embryos are the most beautiful embryos that ever underwent meiosis. Of this I am certain. They were petite, well-behaved, symmetrical—and brimming with personality.
I am dangerously besotted with them already.

Of twenty-two eggs retrieved, seventeen fertilized without ICSI. We have seventeen zygotes bobbing in their culture medium in a laboratory across the river.
Oddly, my first thought after I got the fertilization call this morning was that everything has gone so perfectly—too perfectly—that this cycle cannot possibly end well. I assume this thinking is yet another undesirable consequence of reading excessively, and I am endeavoring to remind myself that sometimes things really do work out, sans tragic plot twists, even if it makes for a rather dull narrative.

I am shocked, and very, very happy. Transfer is at 11:45 on Tuesday morning.

At 8:30 this evening, Scott gave me the trigger shot. There was a brief panic when we realized we weren’t exactly sure where the shot was supposed to go. “Upper outer quadrant” seems suddenly vague when you are about to plunge an inch and a half long needle into it.
And then I couldn’t draw all the medication out of the vial without sucking in air. And then when I tried to remove that air I shot a bit of trigger out of the needle, wondering fleetingly whether it was enough to affect the potency.
And then I shrugged my shoulders, pulled down my pants, and handed Scott the syringe.
Tomorrow, for one glorious day, I have no shots at all. I normally give my morning shots at 6:30; it has been weeks since I’ve slept past six. Tomorrow I will stay home from work, sleep in, and start gathering things for post-retrieval: movies, sweatpants, books, and malleable cheeses. My brother is hosting a Stinky Cheese Party on Saturday that I will be missing, and so I may have my own little soiree with a nice Tallegio and some old William Powell and Myrna Loy movies.

The final numbers:

Right Ovary:
20, 19.5, 19, 17.5, 16, 15, 14.5, 14.5, 13, 12, 9

Left Ovary:
21, 19, 17, 16.5, 16, 16, 15.5, 15.5, 15, 12.5, 12.5, 12, 11, 11, 11

Lining:
9.5C (No idea what the “C” means—”satisfaCtory?” “Capable of sustaining life?” “Cruelly inhospitable?”)

E2:
3121

I am shocked to have gotten this far, grateful for my good fortune, and oddly proud of myself. They are expecting to get about 15 eggs, and retrieval is 8:30 Saturday morning. Stay tuned for part three of the IVF Primer, to be titled Egg Retrieval: or, “They Put The Needle WHERE?”

Today after the ultrasound I did a happy little Charleston before donning my underwear:

Right Ovary:
13.5, 12.5, 12, 11, 11, 10.5, 10 (plus 5 follicles@ 9 and 1@ 8mm)

Left Ovary:
15, 15, 11, 10, 10, 10, 10, 10 (plus 2@ 9.5 and 2@ 8mm)

Lining:
7.8 (I know nothing about linings, but this is up from 5.6 on Friday, so at least it is going in the right direction).

I go back Wednesday and will either trigger that night or the next for retrieval Friday or Saturday. I am quite pleased with myself. Now, before you get too excited, it is my understanding that most of the smaller follicles will not be large enough by retrieval to contain mature eggs. But I’m going to have a retrieval. I never thought I’d be so delighted by the prospect of a needle puncturing my vaginal wall! As someone who ovulates no more than once a year and couldn’t manage even an IUI without being canceled, it feels wonderful just to have a chance at pregnancy.
And who knows, the follicles at 10 could catch up, right? Am I correct in assuming the seven @9 are a lost cause? Those of you with more experience with these things, feel free to make your predictions now.

I switched to the Follistim pen over the weekend, after I ran out of Bravelle and a very kind and dear friend of mine donated her leftover meds. I have read that the Follistim cartridges are slightly more potent than Bravelle, so perhaps that helped to kickstart things. Even my left ovary decided to cooperate, in celebration of which I am taking it out for sushi this evening. Technically I will be bringing the right one along as well, but Lefty is the guest of honor. Ultrasound indicates that my ovaries are biggish, which explains my painful undercarriage. In fact, it has been particularly bad since the ultrasound—I feel as if I constantly have to pee, only I don’t. It is not unlike the feeling one has in the beginning stages of a kidney stone, which is a little unsettling, for obvious reasons. Sitting down is quite unpleasant as well. Perhaps my favorite nurse was a bit indelicate with the ultrasound wand? Surely my lurking kidney stone has not chosen now as the time to come sluicing down the tubes. I suppose I should expect to be uncomfortable with 25 follicles, even if some of them are wee.

Also, there is a mystery afoot—The Case of the Unevenly Discolored Abdomen (working title):
I switch sides every day for my shots, and yet I only bruise on the right side. Looking at my left side you would never know I have been sticking 2-3 needles in it every other day, but my right side appears to have been assaulted by a gang of street toughs. A gang of street toughs with dire anger management problems. In my case, the answer to “If you prick me, do I not bleed?” seems to be “It depends.”

I really do want to post about my visit to the hematologist, but I am in an excellent mood right now, and even thinking about that appointment makes me sick with anger, so I will hold off until tomorrow. I would like to enjoy my glee as long as possible.

******

Favorite Nurse just called: My E2 is at 881, up from 127 on Friday. Hmmm. That is quite a jump, n’est-ce pas?

I first noticed it yesterday—sharp pinches coming from my ovaries. After the call with my low E2 number, I decided it must be my imagination. Today, though, there is no doubt: I am bloated, and my ovaries ache. In bed this morning I could feel them resting in my abdomen, particularly on my right side, where the Good Ovary is. God only knows what Lefty is up to.
The spotting has stopped entirely, which is a relief, but still I am uneasy: I am fairly certain there are follicles in there, as that is the only explanation for the (uncomfortable, actually) fullness I am feeling. But what does that mean? Why is my E2 so low? How does one normally feel on day five of stims? I am ricocheting back and forth between fears of under- and over-stimulation. I doubled my Bravelle today, as instructed, and I suppose there is nothing to do now but go out for a delicious Szechuan dinner with my brother and wait.

Tomorrow will be busy. I have an ultrasound and bloodwork in the morning, and an appointment with a hematologist in the afternoon. Scott is coming with me to my morning appointment, in case things go badly and I am too busy shouting expletives to drive myself home. He was very upset by yesterday’s news, and I think that has been one of the hardest parts of this cycle so far. There was a time when I would have sold my left ovary (not a terribly enticing offer, I know) for him to be as invested in our attempts to get pregnant as I. Well, I got my wish: the pregnancies of his friends make him sad now, and he can’t bear to pass through the baby section at Target. When I told him about my E2 level yesterday, he peppered me with questions, panic in his voice,
“Does that mean you’re not producing eggs? Does that mean this isn’t going to work?” And all I could say was I don’t know. I don’t know.

I know you’re not supposed to feel guilty, that couples are infertile together, regardless of whether they are dealing with male or female factor. But I do feel guilty, terribly so. Scott’s sperm are obnoxiously healthy, and if he had married The Other Alexa (he dated another—obviously inferior—girl named Alexa not long before we met) he would probably have a passel of strange, Habermas-reading kids by now. I am the reason we are spending all of this money, the reason that when we do get pregnant it doesn’t last, the reason that this IVF cycle is off to such a perplexing start. It is my body, my ovaries, my hormones that have failed to produce a child.
Of course I like having the company (misery loves it, you know), but I hate to see him down here in the trenches with me.

The series of events that led to me administering my first stim injection alone in a hotel room twenty stories above downtown Minneapolis involved lightning, a pubic hair, a housekeeper in a Hijab, and 100,000 homes left without power. That description makes it sound rather more interesting than it was—you will have to trust me when I tell you that the story does not bear repeating. Suffice it to say I am back in the land of internet access, and just in time to see that someone found my site by searching for “OLDER LADIES IN SATIN GIRDLES.” Oh information superhighway, I missed you so.

IVF Primer, Part Two: Stimulation
(Part One)
So, you’ve been taking daily injections of Lupron, and will keep on doing so until retrieval, though many protocols have you cut your Lupron dose in half when you start stims (mine doesn’t). Next you will have your suppression check, and if your ovaries are suitably cowed and compliant, you will be given the go ahead to start revving them back up again. This will be done via once or twice daily injections of the same hormones your body would produce in a natural cycle, given at much larger doses. The other difference between the hormones you produce naturally and those you inject during an IVF cycle is their provenance. Some of the hormone preparations are made from the ovaries of Chinese hamsters, others are made from good old fashioned nun pee.

Why nun pee? I’m glad you asked!
Post-menopausal women have vast quantities of FSH and LH (the hormones used to grow and mature eggs) in their urine, dumped unceremoniously into the bloodstream in sort of a hormonal going-out-of-business sale. This urine is collected and the hormones extracted and the resulting powder packaged in wee glass vials. Of course you wouldn’t want to use post-menopausal urine that had been steeping in gin and cigarette smoke (or would you?), so nuns are the obvious choice. They are both clean living and tend to dwell in packs, making it easy to gather gallons of virginal piss in one pass. I don’t know if their piety makes a difference, but I have caught myself humming “How Do You Solve a Problem Like Maria?” a few times since starting stims.

Injecting these hormones causes your follicles (the fluid filled, egg-containing sacs in your ovaries) to grow, and the eggs within them to mature. It also causes your estrogen to rise. If your estrogen gets too high, you are at risk for a particularly unpleasant complication called OHSS. People with lots and lots of follicles, for instance those with PCOS, for instance me, are at even higher risk, so let’s avoid that subject altogether, shall we?
Every other day or so, you report to the clinic to have an ultrasound to measure your follicles, and bloodwork to measure your estrogen level (E2). When you have a crop of evenly sized mature follicles, with about 100-200 units of estrogen per mature follicle, you will be instructed to take a precisely timed injection of HCG (another hormone) to prepare your eggs for ovulation, and your retrieval will be scheduled for 34 hours hence.
-FIN-

I am two days into stims and already feeling some odd pings in my ovaries. Surely this is much too early to be feeling pings? Perhaps it is my imagination, long known to be the most only fertile part of me. Still, I was thinking of reading my ovaries The Tortoise and the Hare as a bedtime story.
The injections are going well, for the most part. I am fairly certain I could give myself a Lupron injection while locked in the trunk of a moving car, but for some reason the stims have been less successful. And by “less successful” I mean “farcical.” In only two days I have:
1. Mangled finger removing stubborn cap from needle (cap came off suddenly, needle skidded along finger)
2. Forgotten to remove cap from one of the vials resulting in broken tip of mixing syringe
3. In attempting to remove air bubble, squirted out a bit of expensive medication
4. In panicked attempt to salvage precious drops sliding down needle (see #3, above), PLUNGED needle forcibly into stomach with no icing and an excess of force

You get the idea. Obviously I am a natural.

Predictably, the headaches and night sweats started as soon as I hit “publish” on my last entry, the one that asserted that I “haven’t noticed much in the way of Lupron side effects.” Hubris, you bastard.
Also, the period I mentioned? Sometime that night it disappeared, replaced by spotting. Now, I am grateful not to be writhing on the floor in agony, don’t get me wrong, but my baseline scan is tomorrow, and I don’t need additional factors to worry about. For those of you playing along at home, here is a partial list of the thoughts frantically cartwheeling through my mind:

Do I have a cyst?
What if my lining isn’t thin enough?
If all is clear at tomorrow’s scan, will I be starting stims right away?
What if I still haven’t had a full period?
Why is my scan only three days after stopping the pill?
What if I get my period AFTER starting stims?
Will eight days of Lupron at 10 units have been enough suppression?
What dosage of stims will they put me on?
Will it be too much?
Too little?
Why are they using Menopur with the Bravelle rather than a straight FSH protocol?
WHAT IF THEY FORGET I HAVE PCOS AND OVERSTIMULATE ME AND I AM CANCELED AND DEVELOP SEVERE OHSS AND DIE AND MY CORPSE IS TOO BLOATED TO FIT PROPERLY IN A COFFIN WITH THE LID CLOSED AND MY BRUISED, DISTENDED BELLY BALLOONS OVER THE CASKET TOP, FRIGHTENING THE MOURNERS?

You can see from this last bit that I am having limited success with my “worry about one thing at a time” plan. Well, actually, that’s not entirely true; I was feeling quite calm and collected until today, the day before Forbidding Hurdle #1. It is not helping that I have never met my new doctor, the one looking at my chart after every visit and making decisions about dosage changes and cancellation. And I’m not going to meet him, at least not anytime soon. After several days of phone tag with the scheduler, and two rather pathetic phone messages pleading for even five minutes of the good doctor’s time, I got a call this morning informing me that his first opening is Thursday, August 23rd.

Hmm. Does that date ring a bell for anyone? IT IS MY TENTATIVE RETRIEVAL DATE. A bit late in the game for introductions, don’t you think? I wanted to meet the person who would be overseeing my cycle, so that I felt sure he knew me and my history, because god only knows whether my chart is complete. And I’d like him to be able to put a face to the ovaries—there is something unsettling about meeting a doctor for the first time when you are heavily sedated and he is swabbing your cervix.
Everyone who knows him assures me I will be getting excellent care. He was a pioneer in the field, responsible for the first IVF birth in the state. He is involved in clinical studies, wears adorable bowties, and is by all reports a delight. But I still wanted to meet him, so that he can see how utterly charming I am. And because this cycle is more or less in his hands.

I consider my self quite knowledgeable about infertility treatment. I keep up on research, I understand the mechanics of the endocrine system and PCOS, I am well-versed in diagnostic procedures and normal lab values. But for once I am completely out of my league. I have read and read and read about IVF, but, really, the only way to understand specific dosages and protocols and how you might respond to them is through experience. Of which I have none. I am not used to feeling so uninformed and reliant on the judgment of my doctors. Those of you who have been reading for a while may have picked up on the fact that I can be an insufferable a bit of a know-it-all. At the risk of sounding terribly conceited, I haven’t run into much that I don’t understand, or can’t come to understand with a bit of reading. And this understanding has helped me feel like I have some control. It sounds rather stupid, but it has been important to me to know what tests to request and what my lab values mean so that I don’t have to take someone’s assertion that “everything looks fine” for granted. I have been at this fertility thing for almost three years, but with the start of IVF, I am back to feeling like the rankest beginner, with very little idea of what to expect and an uncomfortable, creeping awareness that I have absolutely no control over whether this cycle works.

I will post after my scan tomorrow. Until then, please think stern, repressive thoughts toward my ovaries.

IVF is like tax law in that it is generally only interesting to and understood by a small, obsessive coterie of practitioners. Unfortunately for my non-infertile readers, it will be the main topic of conversation here for the next several weeks. Believe it or not, an IVF cycle can be quite thrilling, but only if you know what the hell is going on. So, I thought it would behoove me to explain the process (or at least the process involved in my particular protocol) as we go along.

The premise is simple. Your own reproductive hormone mechanisms (which presumably haven’t been doing you much good anyway) are forcibly shut down so that your cycle can be manipulated by your puppetmaster Reproductive Endocrinologist, who will instruct you to inject precise amounts of hormone aimed at producing 10 to 15 mature eggs, rather than the one you would ovulate in a normal cycle (unless you are like me, in which case a normal cycle is one in which you produce no egg at all). These eggs are surgically retrieved from the ovaries and combined with sperm in cunning little dishes. Hopefully some will fertilize and divide to become embryos. Two-ish embryos will be transferred into your uterus, and any high-quality leftovers will be frozen. If you are lucky one of the embryos will implant, and if you are even luckier it may grow up to be a whole, live baby.

Today I started the first part, the forcible shut down of my own reproductive system. Well, truthfully it started some weeks ago, with birth control pills that I will continue to take through next Monday, but this morning at 7:00 I began injections of Lupron. Lupron turns one’s ovaries from nubile, fresh faced milkmaids into wizened schoolmistresses with Kleenex in their cardigan sleeves and tragedies in their pasts that have left them bitter and unable to love. It also ensures that your body doesn’t ruin things by ovulating, sending eggs slaloming down your tubes before they can be retrieved. It may seem odd to begin a cycle designed to produce many times the eggs of a natural cycle by suppressing your ovaries until they are withered, smoking husks, but think of your ovaries like new army recruits, or an unruly stallion Pa brought home to teach you a lesson about perseverance: first you must break their spirit. Only then can you methodically train them, building them up until they are docile, well-behaved, and can kill a man with nothing but a pop tart and a drinking straw. Or something. The point is, Lupron slams you into faux menopause as your hormone-producing gears grind to a halt.
A week after I start Lupron I will have an ultrasound and bloodwork to ensure that I am properly suppressed. This is my first looming hurdle of the cycle. Though it ultimately suppresses the ovaries, Lupron works by first causing your pituitary to dump all of its gonadotropin releasing hormone into your bloodstream. After this surge, no more is released, causing the crone-ifying effect described previously. However, sometimes the initial hormone dump will encourage the growth of cysts, which might cause your RE to cancel your cycle. So if you feel a palpable hum of anxiety in the air the night before my suppression scan, don’t worry—that’s just me, willing my ovaries into submission.

For now, I am only permitting myself to think about that first obstacle, the suppression check on August 9th. Yes, there are many spectacular ways this cycle could go wrong, but I can only focus on the one immediately in front of me. Otherwise my mind scampers forward from failed suppression check to cancellation before retrieval to cancellation after retrieval to poor fertilization to bad embryos to negative cycle to chemical pregnancy to no heartbeat to miscarriage after heartbeat to stillbirth to SIDS all the way to Kid in College, Never Calls. It takes years of practice to worry so efficiently that within 45 seconds you are fretting about events 20 years in the future, so I wouldn’t try this at home. As much as I would like to relax during this process and not worry about anything at all, I think the best I can hope for is to confine my neurosis to one potential disaster at a time. Of course horse tranquilizers might work as well, but I hear they adversely affect egg quality.