Trauma, Recovery, and IVF

When I was sixteen, I went through a tough event at high school. I won't get into the details here except to say that it taught me one important life lesson. That lesson was that there is no cavalry coming. No one is going to save you. You are responsible for saving yourself. Bad things happen and even if you played no role in causing them, that doesn't matter. There won't always be justice and the people you trust to protect you won't or can't help you when you need them. As Blazing Saddles illustrates, son, you're on your own.

That traumatic event is connected to my recent departure from the blogosphere. (And let's just pause for a second here to acknowledge how very small my corner of the blogging world is: I do have a handful of regular readers, but most people who visit my blog are searching for pictures of my pregnancy tests so they can compare them to their own; sorry, guys, for letting you all down. Hope you found someone else's urine to look at.) It's connected because in both cases I felt completely blindsided by a tremendous life change, I looked to people in positions of authority for help and comfort and didn't find it, and it took a very long time for me to recover psychologically. That's how I feel about my infertility diagnosis and treatment experience, from the distance of almost two years: it was a trauma. A huge, life-altering trauma that still has me floundering.

To bring you up to speed, here's a brief synopsis of events that have taken place since O's birth last fall:

October: Have baby. Labor and delivery go pretty smoothly and we are blessed with a healthy, adorable, bouncing baby boy. I notice that I have a few weirdly obsessive nights where I keep thinking about the birth, and it takes much longer to feel physically "recovered" than my doctors predicted, but I move on to focusing much more on my delicious little newborn than my IVF cycle, my pregnancy, or my delivery.

December: 6-week followup appointment with OB. Have promising ultrasound showing no major endometriosis-related problems, decide to start the mini-pill, generally feel optimistic about life.

January: Go back to work. O starts daycare, immediately gets a series of minor colds and coughs, and everyone's sleep and commuting schedules suffer. Still, as the days get longer and the sleeping arrangements get back on track throughout the spring, I continue to feel pretty great.

April: Find out that the events of the past year and a half have had external consequences that I genuinely didn't see coming. Memories and anxiety that had previously been held at bay come flooding back. Another ultrasound shows that my endometriosis is about as quiet as I could hope, but it doesn't matter, because everything else is completely falling apart.

June: Find out that our current insurance plan - the one that covers four cycles of IVF at one clinic and one clinic only - will be ending in June 2014. Would we like to have another child between now and then?

July: After a tremendous amount of discussion, agree to see a therapist. Spend 45 minutes of a 60 minute appointment grilling her on her treatment style, philosophy, approach to patient care, and make her agree to send me a copy of her notes. Tell her the digest version of what's happened in my life since 2010 and she makes some sympathetic noises. Three weeks later she actually does send me the notes, which thankfully are unobjectionable but are also completely unhelpful. Decide not to return.

August: Go for appointments at two different fertility clinics. Clinic 1 is where we went for the fresh cycle that created O and where I left my egg retrieval feeling utterly destroyed (a feeling I re-experience daily and which generally leaves me sobbing and gasping for air, but which seems weirdly right when we actually have to walk into their building again.) Clinic 2 is brand new in every sense of the word - their offices are still partially under construction, even.

Here's what we learned at Clinic 1: they consider me a success story, what with my single cycle of IVF and my single embryo transfer and my term birth and my (if I do say so myself) utterly gorgeous son. The conversation takes a bit of a turn when I mention that I think about my egg retrieval all the time, I'm completely haunted by the memory of it, I'm generally miserable, etc. etc. Our RE is sympathetic about my bad experience and understands why I would choose to go elsewhere for further treatment, but it's clear that the financial implications of my insurance coverage are not his area of expertise. We talk about how to transfer embryos to another clinic if need be. We also talk about what would be involved if I chose to somehow get past my earlier experience and have a Frozen Embryo Transfer (FET) cycle with them. It's nowhere near as invasive as what I went through before, obviously, and they even say they prescribe Crinone for progesterone support so I wouldn't have to do those vile progesterone-in-oil shots. And to his eternal credit, right before the end of the appointment, our RE does admit that "we tried not to hurt you, but it sounds like we did hurt you a little bit, and we're sorry about that." I leave feeling like we repaired the relationship quite a bit, but part of me wished that I had abandoned RationalCharlotte at the door and taken advantage of the opportunity to scream and curse at someone who was "responsible" for all of my unhappiness. Except I didn't, because he isn't. And while I was sitting in his office and during the weeks following our visit, my anxiety level has continued to be through the roof - especially when I think about even stepping foot in that building again.

And here's what we learned at Clinic 2: they will knock me out during egg retrieval if it ever comes to that (which it probably wouldn't, because that would be very tough for us to afford just paying cash, but it's still the first question I asked.) They're willing to accept a transfer of our frozen embryos and work with us on a FET. They too are sympathetic about how upset I've been - maybe I'd like to try some valium before a procedure, or investigate acupuncture, or join them for Fertility Yoga on Tuesday nights? The price tag for a FET without insurance coverage will be steep but not prohibitive. However, they do use progesterone-in-oil shots, and the minute I hear this the whole world seems to dim for a moment. Those needles are long and thick, injecting them into my ass is humiliating, the process as well as the aftermath is painful, and my heart rate skyrockets when I so much as think about the shots. And even in a new space, with new faces, the mere discussion of what's involved in infertility treatment is enough to make me feel completely terrible.

So, what do I do? Start blogging again, it seems. Other than that I have no idea.

Lovely Lovenox & Comfy Crinone

It occurs to me that advancing in a pregnancy is similar to the wisdom on advancing age that Garrison Keillor once mentioned on NPR: "Getting older is a cinch, you just wait around." And that's what I've been doing, waiting around. I go to work and I come home and I lie on the couch and I fall asleep immediately. I eat something bland every two hours and try very, very hard not to throw up. I review the stages of embryo development on Wikipedia. I obsess about miscarriage, missed miscarriage, birth defects, stillbirth, and what will happen at my ultrasound next week. And I read other IF blogs - more on that in a moment.

But in the meantime, as a sort of public service announcement, I want to write down a short synopsis of my experience with the two newest drugs I've been taking, Crinone and Lovenox. Your mileage may vary, but this is what I wish I could have told past-Charlotte back when she was eyeing these prescriptions suspiciously.

Things to know about Crinone: even though I was promised that it was a unique bio-adhesive gel, it's more like a regular old cosmetic cream. It's white and has the consistency of my facial moisturizer (although I have yet to confuse the two!) It's in a little tampon-esque applicator and it makes a farting sound when you apply it, which continues to crack me up because I am Not Mature. I haven't had any problems with it causing a huge mess, but it is true that it doesn't dissolve 100%, and what is left tends to look like cottage cheese. But since there's not a huge volume going in, there's not a huge volume coming out, either. And the absolute best thing about Crinone (with the exception of the fact that it is hopefully providing the progesterone support that my embryo needs to keep growing) is that it doesn't hurt. Not one little bit. It's a total non-event.

Things to know about Lovenox: this didn't go so smoothly for me at first. Shot #1 with the modified Lindsey protocol (ice for 10 minutes, in fast, push slowly, wait 15 seconds, out fast) was a success, but shots #2 and 3 were a nightmare. Giant, painful bruises that upset me to no end and prohibited me from wearing pants for a few days because they were right where my belt would have been. After some trial and error, I think I've identified the two factors that led to the bruising: one is that the ice, while numbing the initial sting of the needle going into my skin, actually drew more blood to the surface that then bruised spectacularly when exposed to a little Lovenox. Harry pointed this out to me one night when I took the ice pack off and got ready to inject - "You know your skin is all red now, isn't that from more bloodflow going to the cold area?" When I tried it without icing first, sure enough, I got a tiny pea-sized bruise instead of one measuring 3 inches across. The other thing that made the bruising worse appears to have been my pinching technique. As I had with the speedy Lupron and Follistim shots, I was pinching the skin to get the needle in and then holding it in the same position as I injected. The only thing is, when you're injecting a blood thinner over the course of a full minute, that's a long time to be pinching your skin. And that pinch was injuring the blood vessels in my belly just enough that when the Lovenox hit them, they had a field day. I tried not pinching at all as suggested in this video, but that made the needle entering my skin hurt like hell. So my new technique is to forget the ice pack, pinch briefly just long enough to get the needle in, then release, inject the medication very slowly, count to 15 with the needle still in my skin, and take it out quickly. I usually have little to no bleeding from the site afterwards, so I don't put pressure on it or anything, I just fan it a bit and maybe swipe lightly with the alcohol pad if there happens to be a dot of blood. Oh, and make sure you tap the air bubble all the way to the top of the tube before you start the injection, and inject it last rather than first. I read somewhere that it may actually help keep the medication under the top layers of skin where the rainbow bruises would form, and yes, it is safe to inject air subcutaneously. (Not a great idea to inject it into a muscle, vein, or artery, but hopefully that's not where you're aiming your Lovenox anyway.) My tummy is slowly looking less scary and I've even had a few injections go so well that I couldn't identify the exact site 15 minutes later.

Finally, we come to this crappy, crappy week in the world of IF blogging. Most notably, of course, is Mo losing her son at 22 weeks, but there's also Jenny, who had a miscarriage at 9 weeks, and so many BFNs: JM and Lola and Emily and far too many others.  Your words have touched my heart and I have struggled with how to respond - I feel guilty and angry and I wish I could reach out across the screen and give everyone a hug. Since I can't, I will just say that a community is a community in bad times as well as good times, and I'm honored to be a part of it. I hope things get better soon.

Copy That, We Have Visual Confirmation

So although I was genuinely shocked yesterday when I got my lab results, I will confess to you now that it wasn't the first inkling I'd had that something weird might be happening down in ol' Uterustown. The sequence of events was as follows:

Monday - Embryo transfer in the morning, lay like a slug on the couch the rest of the day staring at the picture of my blastocyst. Cramps start around 3 PM.

Tuesday - Cramps continue and intensify.

Wednesday - Cramps continue and start to taper off in the afternoon/evening.

Thursday - Cramps are gone. Totally convinced that nothing was happening, besides the increasingly worrisome pain in my right leg.

Friday - Told I had a DVT in my calf and all hell breaks loose. Upon arriving home at 7 PM, decide to take a HPT even though it's only 4dp5dt since the result might have a huge effect on my treatment for the clot. It's negative, as expected. I sigh and toss it in the trash.

Saturday - Come down with a raging cold. Now I'm sneezing and coughing and my leg hurts and I'm lying around watching reality TV generally feeling sorry for myself. Near the end of the day I'm fooling around on my iPad and decide to Google side effects of Crinone, the progesterone gel I'm using instead of progesterone in oil. Sure enough, breast tenderness and enlargement are listed, which explains why the girls are starting to ache a bit. But then I look at a few message boards where women have discussed their experience with Crinone and most of them mentioned that their breasts started to hurt within a day or so of beginning Crinone, whereas mine only began aching a week and a half later. Huh. Before I go to bed, I take another HPT. It's also negative. This time I leave it on the edge of the sink and go to sleep.

Sunday - Harry was gone overnight, which was a good thing because I woke up early due to all the sneezing. This time I have some pretty concentrated urine to use for a test, so I take another one. It's negative again, so I flop back onto the bed and start Googling "6dp5dt BFN" to see whether it's possible that I might still be pregnant despite the negative result. But the cat is crying for his breakfast and the dog needs to go out for her walk so I drag my congested self out of bed to put in my contacts and start the day. I look back at the test and I see - no. No, wait, it's impossible. There's something there. It's a line. It's a faint line, but it's there. Wait, really? I have other tests under the sink. My hands are shaking so badly I can hardly get the box open. I take out a First Response Early Result, which is apparently the gold standard of early home pregnancy tests. While I'm waiting for the results, I compare the 6dp test to the 5dp test and the 4dp test. When you line them all up next to each other, you can see that there were very very faint lines after all. If I had seen them earlier, I would have chalked it up to wishful thinking or an evaporation error. I look back at the FRER. There are two lines on it. It's real. This is happening. I walk back into the bedroom and stare at my surroundings for a moment, bewildered, and then burst into tears. I think of Emma Thompson at the end of Sense and Sensibility when Hugh Grant tells her that he's not married and finally professes his love. I am not the only one crying. The cat is now standing on the bed meowing at me at the top of his little lungs that I am late in serving him breakfast. I can hear the dog down in the kitchen starting to whine that she needs to be let out. There is no choice but to start the day - pregnant. I am doing all of these things while I am pregnant.

When Harry comes home, I am incredibly impressed with my acting abilities. I'm in the kitchen doing food prep for the Superbowl later that night and I make some remarkably normal small talk. I say that I need his help changing the sheets on the bed and he follows me upstairs. We're standing next to the bathroom when my act starts to falter. I say weirdly "Oh, and there's something else I wanted to tell you" and I push the door open. I've lined all the tests up on the edge of the sink, including a digital with an unmistakable "Pregnant" result. He walks in, takes one look at them, and throws his arms around me. We're happy. We're freaked out. We're cautious because the lines are so faint. We're debating when to have a baby shower. We're wondering whether we should buy a house. We're speculating about whether it's a boy or a girl.

For your viewing pleasure, here's the picture of the FRER at 6dp5dt:

And here is the progression of Wondfo tests from 4dp5dt to this morning:

And while everything looks promising so far, I want to say that I have been convincing myself about once every hour since Sunday morning that this is a chemical pregnancy. Or that I am destined for an early miscarriage. Or a stillbirth. I'm so freaked out about all the things that can go wrong. I feel like I have never read a blog written by a woman who went through one IVF cycle and actually had a healthy pregnancy at the end of it. And those Wondfo tests are particularly worrisome: um, they are nowhere near as dark as I would like. If the amount of HCG in my body is doubling every day, then why aren't the lines twice as dark? I'm out of FRERs and I've debated buying more just to put my mind at ease, but that seems silly since my clinic is going to give me a much more accurate result after my second blood test tomorrow morning. And they're going to keep testing me to make sure my HCG keeps increasing, and then do ultrasounds to make sure that the pregnancy is progressing normally, and the reality is that this is a level of uncertainty I am just going to have to live with until the day I hold my baby in my arms. Then a whole new level of worrying will begin!

The only thing that helps is repeating a mantra that I've seen recommended for women who are pregnant again after a loss: "Today, I am pregnant." And it helps - today, I am pregnant. Today, I am grateful. There is nothing I can do except cultivate patience and calm for the tiny person growing in my belly. In a way, I think that everyone who gets pregnant after struggling with infertility has already struggled with a loss - the loss of our innocence. I feel joy about this pregnancy, but I know it can be taken away in an instant, so my joy is nearly equal to my terror. I also feel honored to have received so many positive comments on yesterday's post - thank you, thank you, thank you all. I hope to have more good news to report soon.

These Meds are Worth More than my Car

As we were walking into the hospital for my surgery, I caught a glimpse of a doctor in scrubs and a surgical cap through a window and I thought I was going to pass out. I said out loud to Harry, "This is the worst," and I almost turned around to go back to the car.

Yesterday, I picked up a Chinese-takeout-sized bag full of hormones, syringes, and antibiotics from the pharmacy. I had the same reaction when I laid it all out on the dining table at home. This is the worst the worst the worst the worst. These are the medications for a sick person, right? Look at how many of them there are! Look at all those needles!

Okay, Charlotte, let's calm down a little bit here. Take things one step at a time. What are these, and what will they do?

First up, the leuprolide acetate. Note that this is not brand-name Lupron, which I appreciate since my copay was significantly lower. This quiets down my ovaries to the extent that they tell my body I'm in menopause, so really, I see this one as an exciting little glimpse into the future. Side effects apparently include the following:

Leuprolide will cause an initial flare in testosterone or estrogen levels leading to bone pain, urinary problems including blood in the urine, and tingling in the feet and hands.
Common side effects: irregular menstruation, bone pain, sweating, dizziness, water retention, hot flashes, headache, nausea/vomiting, and pain at injection site.

Awesome. Next up, I think I can figure out what this one is:

Follistim will get my ovaries out of artificial menopause and into overdrive. Eggs? Did somebody say to make eggs? Hey everybody! It's egg-making time! I'm told this is the most expensive of my medications, so I'll try not to inadvertently confuse it with the cheese and butter it's sharing space with in the fridge. (I also probably shouldn't have accidentally dropped the pen and then kicked it partially across the room when I was trying to gather everything up at the pharmacy, but live and learn.) Side effects:

The most common adverse reactions (≥2%) in women undergoing controlled ovarian stimulation as part of an IVF or ICSI cycle are pelvic discomfort, headache, ovarian hyperstimulation syndrome, pelvic pain, nausea and fatigue.

So we have that to look forward to. Next is a single, unassuming little tube... Ovidrel! This one will make my hyperstimulated ovaries get ready to release all those eggs they just made - and it will be perfectly timed so my doctor can get in there 36 hours later with a scary-looking needle and grab them before they all head off for their various adventures. Ovidrel warns me:

The most common side effects in women using Ovidrel® include abdominal pain, injection site reactions, nausea and vomiting.

But after ovulation, the fun isn't over: for two weeks, and longer if I actually do get pregnant, I get to apply a "unique bio-adhesive gel" to my cervix, Crinone. Not going to lie, this is the only medication I am kind of curious about, because A. it probably won't hurt, and B. unique bio-adhesive gel? Sounds super space-age! Also, I understand that this replaces the progesterone in oil shots that other women have complained about, so I was pretty stoked to see it on my list of meds - even if it will be messy and gross. Side effect info:

The most common side effects of CRINONE (progesterone gel) 8% include breast enlargement, constipation, drowsiness, nausea, headache, and pain in the pubic area.

Let's not forget the various antibiotics I'll take for a few days at different points in this process, or the prenatal vitamins and baby aspirin I'll take throughout, or the additional meds I will have to start if I am knocked up. First, one thing at a time. Leuprolide acetate begins on Dec. 12th.