Next Steps and Continued Hormonal Funtimes

Hey, look, we've made it to six weeks! Good job, everybody!

Six weeks means that O is smiling (sometimes), cooing (occasionally), and extremely cute (all of the time.) It also means that I had my six weeks postpartum checkup, which ordinarily would have focused on healing Down There and birth control plans, but was a bit more interesting for me. The endometriosis that got us into this whole IVF mess is a problem that won't go away, so there are a few things we're going to continue to monitor going forward.

First of all, some good news. I passed another milestone this week: I'm off Lovenox! No more enoxaparin sodium for this girl, at least until/unless I get pregnant again. For those of you keeping score at home, this was nearly a full year of daily injections, with a few short breaks here and there. Someday I'll post the total number of needles that it took to get O from theory to reality, but for now I'm content just watching the bruises fade.

Also, the preliminary results suggest that the endometriomas have not recurred (or are pretty small if they did.) The one on the left was 4 cm right before my IVF cycle and we'll see what continued breastfeeding does to keep things quiet. I've seen it described as "natural Lupron," which would be nice since I want to avoid taking that stuff again if at all possible.

Since I had a complicated pregnancy, I also wanted to go over whether I'd have to be concerned about attempting any other pregnancies in the future. Yes, I will likely have to be on Lovenox again, but my risk of placenta previa is only slightly higher than normal and the fact that it resolved this time is a good thing. I also had some weird liver stuff that popped up on my bloodwork at the very end, but that just means they'll be on the lookout for pre-eclampsia as they would for anyone. Overall, I guess I'm not a terribly complicated patient when it comes to another pregnancy, which is nice!

Now for the tricky stuff. The endometriosis which caused my tubes to scar over and my ovaries to grow endometriomas will theoretically get worse every time I have an ovulatory cycle (though how much worse, and how much it will bother me, is kind of a question mark.) Ordinarily I would probably be prescribed a combination estrogen/progesterone birth control pill, but thanks to my DVT, I'm not a good candidate for that. I'm likely headed towards a progestin-only pill or maybe a Mirena IUD - and yes, I really am considering taking the pill despite my earlier protestations about systemic hormones. Why? Well, partially because the side effects are theoretically less problematic than the combined BCP, and partially because I can wrap my head around taking a pill if I know it's only for a short period of time.

All this to say: it's a matter of time before we're back on the IVF train. Don't think I've forgotten about those three embryos on ice, and because of a combination of family and medical factors, we're probably looking at attempting another cycle in a year. Or less. Or maybe a little bit more. There are a lot of moving parts to consider, even though we're committed to giving O a sibling - or at least trying our hardest to do so. We've been so blessed to have him, and I hope and pray that our luck continues!

5 Things I Didn't Expect About Labor, Delivery, and the Postpartum Period

Little O is almost a month old - I'm so proud of him for thriving, and us for surviving! He's packing on weight like a champ and we're getting better at keeping our household functioning with a newborn as its newest member.

Before the memories fade, I wanted to write down some of the most surprising things about my birth experience in case they're helpful to someone else (or in case I choose to do this again - but that's a different story!)

1. Braxton-Hicks contractions vs. real contractions. 
For most of the pregnancy, I felt not-quite-painless Braxton-Hicks contractions at least once a day. Toward the end of the third trimester, they were very frequent (but never regular, usually coming in clusters a few minutes apart and then easing up for an hour or two.) I spent more time than I'd like to admit looking up phrases on Google like "distinguish braxton-hicks contractions labor" since I was constantly convinced I was about to go into preterm labor. One of the things I read often was that Braxton-Hicks contractions feel like they start low in your uterus and then sweep upwards, but real labor contractions wrap around from your back to your front, or sometimes they seem to move from the top down. As I've written previously, once I felt my first real contraction I realized how different they were, but only in terms of the pain associated with them - every single labor contraction I had went from the lowest part of my uterus up to the top, just like the Braxton-Hicks. They were, however, much more painful and felt very similar to menstrual cramps. If you're trying to make the distinction on your own, I would say that the way you perceive the tightness starting is not the way to go.

2. "You're so tall, maybe that's why the epidural isn't working."
I was pretty clear with all of my caregivers before and during my labor that I wanted an epidural. And I got it, too, which I greatly appreciated. However, several times while trying to fix the window in the lower left quadrant of my belly, the nurses and anesthesiologists remarked that maybe it wasn't working correctly because I was so tall. Huh? For the record, I'm 5'8" (about 173 cm for you metric folks.) I'm tall, but not that tall! I can't imagine I'm the tallest woman who has ever given birth at this hospital, but who knows. Besides, there are lots of risk factors for why the epidural might have been incomplete at first, and it's a common problem that often has a simple solution. In any event, after lots of fiddling and a bolus or two of extra meds, the numbness did spread over my entire contracting belly and I was a much happier mother-to-be. Bottom line: if you find yourself with an incomplete epidural, don't give up - ask for them to do whatever they can to fix it.

3. Careful with that bassinet!
Well, duh, I don't want to drop my precious bundle of joy. Then why is the bassinet so high, and my hospital bed is so low? Once the excitement from the birth had settled down and O and I were moved to a postpartum room, the nurses got me into a nice cushy hospital bed and put O right next to me in what is, let's face it, a modified refrigerator crisper drawer on wheels. Since the nurses and doctors would stand when they checked out O, it made sense for him to be nice and high (think the height of a kitchen counter). And since I struggled a bit getting in and out of bed, it made sense for me to be nice and low. But when I needed to pick up O, things got a bit tricky. I couldn't reach over to get him while still in bed, so I had to either stand up and walk around to the bassinet to fetch him or get up on my knees rather awkwardly while still on the mattress. I tried putting my own bed up as high as it would go, but the nurse got upset at this and came in to lower it because she said I could injure myself trying to get down from there (which, yeah I could, but who would you rather see in a heap on the floor, me or the baby?!) Next time I do this, I'm asking someone to hand the baby to me each and every time, because there's just no good way to get him or her from the bassinet to my arms when I'm by myself.

4. Headlights
Prior to giving birth, I hit up my local maternity store for a nice pretty nightgown that I could wear during my hospital stay since I knew we'd have visitors. I did not, however, pack a nice pretty bra to go with it! I guess that when an infant is spending hours each day sucking on your nipples, they don't exactly go back to their innocuous, soft, no-bra-necessary selves between nursing sessions. Seriously, I looked like I was cold the entire time! I had a sleep bra with me that consisted of a nice, comfy single layer of fabric, but that wasn't enough to preserve my modesty when friends and family started stopping by. Underwires and padded cups are the only way to go, as far as I'm concerned.

5. The sweaty, sweaty night sweats. 
Things were so weird in the hospital that it was hard to tell what was normal and what wasn't, but once I got home, I noticed that during the (very short) times that I slept, I would sweat like crazy. Remember when I was in menopause for a few weeks last winter? It was like that! I thought I was imagining things until I read Mo's post about the same thing, and it turns out that it's a common occurrence after giving birth. Honestly, it wasn't too bothersome (not getting more than 2 hours of sleep in a row was a bigger problem) but it did make it even harder to stay hydrated, which is important for breastfeeding. Keep a glass of water nearby and get ready to do even more laundry than usual, and take heart that it should end soon - for me, it was only about 3 weeks and now I'm back to normal.

Normal... what a crazy idea. Having a baby means embracing the new normal, that's for sure. But I'm saving that for another post!

A Brief List of Things that Recently Made Me Cry

1. A commercial for Pradaxa
2. News stories about the recent tornado damage (this actually makes some sense, it's terrible)
3. The Dixie Chicks' "Wide Open Spaces"
4. The USA Gymnastics American Cup television coverage
5. Finding out that a friend is 10 weeks pregnant

I know the last one should actually have made me happy - if everything goes according to plan, our babies will be born within a few weeks of each other, which is really cool. And yes, it would have hurt even more if we didn't have our own bun in the oven. But... argh. It's really tough to hear that she just felt weird one day and took a pregnancy test and, what do you know, it was positive. As opposed to "injected herself with drugs and cried herself to sleep for months and has horrible painful memories of her child's conception." And, of course, they felt comfortable sharing the news before the end of the first trimester - it must be nice to be so confident.

So, self-pity, party of one? Hopefully, in time, this will become a happy coincidence and we'll be able to look back at all of this and laugh. (Ha. Ha. Ha. Look, I'm already doing it.) And for the record, they have absolutely no idea that we are also expecting - a testament to our acting skills if I've ever heard one. I'm thinking of announcing our news around when the baby crowns, what do you think? If wizard capes become fashionable, I just might have a shot.

Body Art

Is anyone else making designs with the little marks from their injections? No? Just me?

I'm up to a diamond pattern on both sides of my belly button. Trying to figure out how to turn them into a star before they start fading. I'd post a picture but it's not actually that pretty!

Charlotte vs. the Birth Control Pill

The day after my surgery, my doctor called to recommend that I start taking the birth control pill. It made sense - endometriosis gets worse every time you ovulate, and the BCP stops you ovulating - and because of the timing of my surgery I could have started a new pack of pills immediately. Intellectually, I knew this, and I was expecting to hear this advice, so naturally my reaction was to start crying and begin making vague legal threats about how the only thing that would get me to take the pill was a court order and this is America and there's not a court in the country that will force me to take birth control blah blah blah. So, not a productive discussion.

What I should have said (and this happens to me so frequently that I was thinking of titling an entire blog post "What I Should Have Said" and then writing down all the witty, well-reasoned answers that I always think of right when I'm walking away from a conversation) is that I would prefer not to take the BCP because I find the side effects vastly outweigh the benefits. I don't want to start railing against the BCP, which many women find to be very effective. But for me, the three different types of BCPs I have tried produce a change in my mental state that I find unacceptable. I would rather experience physical pain and discomfort from recurring or worsening endometriosis than feel like I have lost myself, especially if that feeling is intended to be part of a long-term treatment. Hormones mess with my head, period. Other women might not experience this, or might not find it to be terribly problematic, but I do. And since it's my body, it's (still) my choice.

So naturally, instead of taking a low dose of convenient oral contraceptives once a day, I have chosen to stick a needle in my belly every night for ~6 weeks to administer huge amounts of hormones in the hopes of creating a pregnancy that, in turn, will send my hormone levels through the roof for months on end. But it's still a more palatable option to me than just going on BCPs and waiting until I felt "ready" to try an IVF cycle. With my tubes all screwed up, I knew that IVF was looming in my future no matter what, and I didn't see any point in waiting around in a depression for months or years until I felt up to plunging deeper into hormoneville (now with extra crying!) And if this cycle fails, which it totally might, I will need to have another conversation with my doctor explaining why I will not take BCPs while we're waiting to start another cycle. My goal if we get to that point is to avoid threatening legal action, but if it ever came to that, I have an idea about where to get a lawyer.

Fun with Anti-Müllerian Hormone

So my post on CD3 reference ranges got me thinking... what is Anti-Müllerian Hormone, and why does it vary so much from woman to woman? Let's see what we can find out. (And by we, I mean me, and since I am definitely not a medical doctor I encourage you to do your own research on the matter.)

First of all, you kind of have to love Anti-Müllerian Hormone (AMH) for having an umlaut right in its name. And why does it have an umlaut? Because it inhibits the embryonic development of a structure named after a Dr. Müller: the Müllerian ducts. I know, usually when going through IVF we hear a lot about blasts and hatching and the really early stages of embryo development, but what happens after that is still pretty cool. Once in the womb, the embryo continues to develop structures that are common to all humans, like a gastrointestinal system (wouldn't want to be without that...), but very early on in the process - as in, during the first 8 weeks - the reproductive organs also begin to develop. And they develop in the same way for everybody at first, by creating the Müllerian ducts. If you're a girl, you want those ducts to stick around - they eventually turn into your uterus, Fallopian tubes, cervix, and most of your vagina. If you're a boy, however, you don't want those ducts to linger. You want Wolffian ducts instead, which eventually turn into the vas deferens, epididymis, and other structures that will someday allow you to (hey hey!) ejaculate. That's where AMH comes in. If the embryo is secreting AMH from the cells that will eventually turn into his testicles, then the Müllerian ducts die off. If there are no early-stage testicle cells creating AMH, those ducts just keep on keeping on, and the baby will be born with the kind of reproductive organs that someone will one day refer to as her downtown dining and entertainment district.

But, you say, I am not an embryo! Why is my doctor measuring the amount of AMH that I, an adult woman, am producing? If I were an embryo, I wouldn't be reading a blog about infertility, now would I? And I respond, because I can hear you all the way across the Internet, that there's more.

Adult women's ovaries also secrete AMH for their own personal use, and it controls the formation of follicles during the reproductive years. Ovulation is actually supremely cool: ovaries have lots of follicles in them that have the potential to become a mature egg, but how a lucky follicle is chosen to mature is not terribly well understood. (I kind of think of the follicles that do make it to ovulation like the Marines: the Few, the Proud. They grow to over a hundred times their original size and have to compete for the privilege of doing so.) AMH's role in this process appears to be as a kind of counterbalance to FSH, which stands for Follicle-Stimulating Hormone and which does pretty much what its name suggests. You need FSH to stimulate your follicles to grow so they can someday become a mature egg, but if you have too much of it, that can also be a problem - hence the role that AMH plays to limit the effectiveness of FSH. AMH is produced by follicles at very early stages of development, and if you take it away, the FSH does its job a little too well. Ideally, you want to strike a balance. More AMH = more early-stage follicles waiting patiently to develop. And less AMH = not as many follicles awaiting their turn to be used at a later date.

Now, AMH doesn't change during the menstrual cycle, unlike some hormones I could name (coughcough FSH and LH coughcough) but it does decline gradually over a woman's lifespan. Your ovaries age, their overall reserve declines, and there are fewer early-stage follicles hanging around to create this "we're waiting patiently" hormone. Most fertility literature relating to AMH focuses on what to do if your numbers are too low, since it's a common problem for women of a certain age seeking treatment. Although there's considerable disagreement on how low is too low for infertility treatment to be worthwhile, anything above 0.5 ng/mL is probably still good, and above 0.15 ng/mL is considered acceptable. Then again, if your AMH is too high, that can also lead to infertility. Your FSH may not be able to do its job at all - there might be too many follicles giving out the "we're waiting patiently!" signal for the FSH to be able to stimulate one to develop, and that can mean you're not ovulating.

But the thing is, like much in the world of infertility treatment, it's important not to look at just one lab value or test result. (Don't forget, there are lots of other hormones involved with this process - it's as complicated as it is fascinating.) And it's equally important to remember that many of these hormones can be messed with through medical intervention so your ovaries can do what they need to do. Women can, and do, conceive with AMH values that don't look perfect. They also conceive with missing Fallopian tubes, strangely-shaped uteri, and after drinking wayyyyy too many tequila sours. Talk to an RE if you want to know more about AMH, but whatever you do, don't mention that you read about this on a :::shudder::: blog. Blame Wikipedia for that. :-)

First Lupron Injection in 3, 2, 1...

So tonight, I am live-blogging my first injection of leuprolide acetate. Okay, so it's not really live - this is the Internet, after all, you have no idea when I'm actually typing anything or if it's even happening - but I promise I'm writing in real time. Near real time, anyway.

This is the first shot I am giving myself ever, which I guess isn't too surprising when you consider that injectable meds are rarely considered the first line of defense for common health issues. I just feel like I should be more confident about it. When I had my IVF orientation meeting I was so uncomfortable with the injection demonstration that I was all smiley and jokey with the nurse and said I had no questions just to get it over with. I was much calmer when we were going over paperwork. Paperwork, now there's something I can do.

The thing is that my questions about the injections are not the ones that she could answer. How much will it hurt? Will the side effects be really bad? Why do I have to do this to have a child and other people just enjoy a well-timed orgasm? (Edited to add: not much; still to early to say; nobody knows.)

Anyway. In preparation for this evening, I've been keeping an informal log of the various "side effect" symptoms I've experienced over the last few days of my drug-free existence, in the hope that I would freak out less when I actually had lab-made hormones running around in my system. For instance, on Friday, I had what felt like menstrual cramps (but weren't); they were bad enough that I considered actually taking some ibuprofen, but then they went away with no explanation. On Saturday, my sciatic nerve hurt intermittently. On Sunday, for about 20 minutes I felt nauseous enough that I was discreetly looking for places to throw up in public if necessary. Okay, so that last one was directly attributable to motion sickness, but my point is that life is full of random little ailments. Most are temporary. Many would never even be worth complaining about. They're no big deal. I NEED TO REMEMBER THIS.

But now I'm just stalling. Ready, everybody? Time to inject some leuprolide. My essential self-injection supplies appear below.

...

And we're back.

If you ever find yourself injecting hormones into your body, I cannot overstate the importance of having a frosted sugar cookie on hand. Please, don't take any risks with this.

But seriously, it wasn't that bad. I cut myself while shaving my legs a few days ago and that was ten times worse, pain-wise. I'm just so resentful that I'm doing this in the first place, which is something I didn't feel when I nicked myself in the shower. (Though maybe I should have been resentful that I was shaving my legs at all, in a sort of second-wave-post-feminist-join-the-sisterhood kind of way?) And I'm also driving myself nuts thinking about the giant hormone molecules currently dispersing themselves throughout my body, just dying to start trouble. I'll be keeping a close eye on them. :::shifty eyes:::

CD3 Reference Ranges

I know I have a legal right to all of my medical records, but it gets a bit tiresome to formally request them every time I have a new test or procedure. This is why I was so stoked when the receptionist at my RE's office just handed me a copy of my most recent lab results to take home, explaining that she had accidentally printed out two copies and did I want one?

Yes! Of course, I love numbers. I wish my RE would share a bunch of de-identified data so that I could start parsing it by age, cause of infertility, drug protocol, stage of embryos at transfer... yeah, keep dreaming. If it isn't required by the CDC, most REs are very reluctant to put their statistics out into the world, and that's a conversation to have another time.

But at least I can look up my CD3 numbers and compare them to others to see if they're normal, or so I thought. Dr. Google was significantly less than helpful in finding standard reference ranges for a healthy, pre-IVF CD3 blood panel - I guess every lab, and every RE practice, does it differently?* In case it's helpful to others, here's what my discussion with my RE nurse revealed:

LH (Luteinizing Hormone) 1.9-12.5 mIU/mL
In a perfect world this would be somewhere between 7 and 12, but the nurse said that it's really only checked against the FSH value. If they're reasonably similar, that's good; if it's twice as much as the FSH, you might have PCOS.
My value: 6.8

FSH (Follicle-Stimulating Hormone) 2.5-10.3 mIU/mL
FSH is a good way to measure that all-important ovarian reserve, so under 6 is said to be good. Other clinics won't work with women who are over 10, but my clinic accepts patients up to 15, so I have room to grow!
My value: 5.7

E2 (Estradiol) 11-212 pg/mL
Ideally, this is less than 75 - if it's high, that suggests not-so-great ovarian reserve. But note that the reference range goes up to 212 without being flagged as problematic. It's a good reminder that you can be a normally-functioning person and just not be very fertile.
My value: 33

AMH (Anti-Müllerian Hormone) 0.65-16.40 ng/mL
Word on the street is that 4.0-6.8 is considered optimal fertility. Higher is better for a successful IVF cycle, although I actually forgot to bring this up during my conversation with the nurse so that's about all I've got.
My value: 5.20

Not gonna lie, I'm feeling pretty good about this, and really lucky. My ovaries appear to have survived the assault from the endometriomas and the surgery with their function basically intact. As I write this, they're sitting around quietly, probably getting ready to pop out an egg or two in the next few days, blissfully unaware that that egg will almost certainly be denied entrance to my Fallopian tube and will instead be forced to wander my abdominal cavity on a brief (but glorious?) adventure before inevitably disintegrating. Hang in there, guys! Your moment to impress us all is coming up soon!

*Edited to add: this page has much, much more information. Thanks for the link, Stirrup Queen!

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.