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!

Three Little Totsicles

In the end, our clinic only froze three embryos. This is way better than zero and has me thinking about creative names for us to use to refer to them while they're sitting around in a freezer (my favorite by far is Knatte, Fnatte, and Tjatte - the Swedish version of Donald Duck's nephews Huey, Dewey, and Louie.) But it also makes me sad.

At our first meeting, when we were discussing the merits of a 3-day versus a 5-day transfer, my RE said something about the best environment for an embryo being, of course, in the womb. The culture mediums that they have in the lab are good, but not as good as what nature provides. So if my embryos were few in number or looked like they needed every advantage in order to make it to term, he would recommend putting them back as soon as possible. Obviously this didn't happen and we went with a day 5 transfer, which meant that eleven of the original fertilized embryos were left in the good-but-not-ideal culture medium for a really long time. I am impressed that three made it, and made it with flying colors and a great quality rating from the lab. But I am really sorry for the eight that didn't. Not all of them were dividing really slowly, which is a sign that they probably wouldn't have survived at all - there were at least two others that reached blast but looked "dark" and not great overall so the embryologist didn't recommend freezing them. I can't help but wonder if maybe we should have chosen one of them to put back in my uterus so that they would have the best chance possible, and leave the freezing to the superstars. Crazy, I know - but these are the kind of thoughts that occupy your time when all you have to do is sit around and think "ooh, was that an implantation cramp or just gas?"

Anyway. The problem with this kind of thinking is that it leads to some pretty sticky issues about a gamete's right to life that I reallyreallyreally don't want to discuss on the Internet. I feel a little bit like Elle Woods arguing that any masturbatory emission where the sperm was not clearly seeking an egg is reckless abandonment. The statistics are that at least one of our frozen embryos will become a living child, and you never know, maybe all of them will. And we did give one of our embryos the best chance we could by transferring it back inside me, so I don't want to lose sight of that.

Reunited

Disclaimer: this is not my embryo. But you'd believe me if I told you it was, right? Because our cell fragmentation rates are so similar? Oh gosh, we get that all the time. :::blush:::

Transfer this morning was similar to what I expected, based on all of my fellow bloggers' many descriptions. I changed into back-to-front hospital gowns and grippy socks, had a conversation with my doctor about how many embryos to transfer (spoiler alert: just one), and then it was on to the big event. I put my feet in the stirrups while my RE put in a regular speculum as though I was about to have a pap smear, then a nurse used the ultrasound wand on the top of my belly to see my uterus. The only wrinkle was that my uterus was at a weird angle, so they kept trying to adjust the table and use a different catheter and finally my RE left the room for a moment while he tried to find one he liked. Yes, that's right: left the room! While I had a speculum shoved up in my personal region! And I had to pee! I overheard some snippets of conversation about someone maybe not having ordered or restocked the catheters correctly... dun dun dun. Anyway, he came back and put in the right catheter, then the embryologist did this elaborate thing with him where they verified back and forth that I was who I said I was and my embryo was who it said it was, and then he said "I'm ready to inject" and I felt the tiniest cramp in my uterus. On the ultrasound screen I could see a little bit of movement, and after a brief pause, he took the catheter out and the ultrasound nurse stopped pressing on my bladder. I chilled on the table for another 20 minutes reading the Golden Globes fashion issue of People magazine, and because I know you're wondering, I will put the matter to rest right now: in the final analysis I don't think I liked Angelina Jolie's dress. Too severe on such a thin figure.

We transferred one embryo, for several reasons:
1.) At my age, and without any reason to suspect other infertility factors, transferring more than one embryo is not likely to increase the likelihood of a successful pregnancy. All it does is increase my chances of multiple births.
2.) We believe in eSET. My unpleasant experience with egg retrieval aside, we are covered for four IVF cycles at this clinic, and we believe that the ethical thing to do is to attempt one birth at a time. Multiples, even twins, have higher rates of complications - which means more healthcare dollars spent by us and our insurance company overall. We have the luxury of making this choice because we do have four cycles covered, although we strongly believe this kind of coverage should not be a luxury.
3.) I just really don't want twins if I can avoid it. I'd rather hear that the cycle failed (and that we are moving forward with a FET) than be as sick as my cousin was when she was pregnant with her boys! She just could not stop throwing up, it was awful. If the embryo splits into identical twins then we'll deal with that when it happens, but I saw no reason to deliberately choose it.

The other reason I feel good about our decision is because this embryo got literally the highest grade the lab gives out. They said that it was always the leader in dividing, day after day, and it was hatching this morning right before transfer. My RE was very impressed by our embryos overall and said that we will have at least three to freeze, though we won't know for sure until tomorrow. So far only one has arrested, so ten are still technically candidates, although a few are going so slowly at this point that it's unlikely they'll make it. Three frozen embryos would be a gift; we went into this knowing that we could have none in the freezer so we're very grateful for whatever we can get.

One final, memorable thing about transfer day: so as I was lying on the table reading People, one of the nurses gave me a printed picture of our embryo. I thanked her and then a few minutes later, when I was finally released to go use the ladies' room, I realized had nowhere to put it. I mean, think about it - no pockets in my hospital gown, no purse, no friendly little shelf in their tiny bathroom holding extra toilet paper, no nothing. I settled for sort of perching it behind the sink faucet and handles, but then when I went to wash my hands, the picture FELL INTO THE SINK!!! And the ink started to run, and I was watching the only picture of the only child I've ever had start to swirl down the drain, and I took it out immediately and tried to blot it with a paper towel but that just made it worse, so there was nothing to do but start laughing hysterically and fess up to my idiocy. I walked out and showed the nurse my sad, wet, grayish piece of photographic paper and she laughed too and printed me another one. I have to say that I hope it wasn't a bad omen, but I also kind of want to tell the kid this story someday to illustrate what a spaz his or her mother was. I promise to treat the actual embryo much better than the picture!

Weekend Update

Unbelievably, all 12 embryos are still hanging in there. I am having visions of Mother Ginger from the Nutcracker.

I am hanging in there, too - I started back on solid foods last night when Harry made me the most delicious scrambled eggs ever (I ate them in tiny tiny bites and couldn't stop exclaiming about how they were the tastiest eggs I had ever had the privilege of eating. Then I had a small bowl of the most delicious yogurt I had ever eaten in my life - what were the odds! It was getting to the point where I was ready to start exclaiming that the water was the most delicious water ever, too.) Today I had a real breakfast, and lunch, and yes we are having steak for dinner. My belly is still sore, but nowhere near what it was yesterday. I hope that the upward trend continues.

Transfer is on Monday morning and I'll let you know how it goes, but my only hope is that nobody attempts to make it a touching spiritual occasion. My friend who has been through this twice at this clinic said that her doctor asked right before transfer if she wanted to say a prayer, and then proceeded to join with her in asking for a little assistance from the divine. Not my style at all - when I pray it's on my own time, not with a bunch of medical staff I barely know. I certainly don't get the sense my RE will bring it up as an option, but I think if he did my only reaction would be amusement, not reverence. And speaking of amusement, that's what I'll be doing in the meantime, catching up on TV shows and trying not to think about things too clearly. "Just relax," right?

What Happened, Food? I Thought We Were Friends

Not burying the lead: all 12 embryos have survived to fight another day. The clinic is planning on a day 5 transfer.

That's the good news. The bad news is that while I had planned to write a chirpy little post about how I was trying to increase my protein intake to avoid  Ovarian Hyperstimulation Syndrome (OHSS), I ended up having a really rough night with the belly pain. I ate an actual meal last night for the first time since Wednesday's nauseapalooza, and I think my GI system did several backflips when it realized it had something substantial in it. I'm sure the doxycycline I'm taking isn't helping matters either. Now I'm racking my brains for ways to increase my protein intake without writhing on the couch for hours - I had a single piece of toast with peanut butter this morning and so far so good. I also brought a high-protein shake to work and it's sitting on my desk, where I am staring at it with apprehension as though it's about to jump down my throat of its own accord and start causing trouble in my tummy.

I mean, at some point my belly has to stop hurting, right? Until then, I'm just going to have to tread carefully and eat whatever I can manage to eat. And I'm also wondering if more dietary protein to avoid OHSS is a good idea at all, since I'm having trouble finding a professionally authored study on this, even though it's all over the infertility message boards as accepted post-retrieval advice. (If you have hard data to back this up, please let me know.) Either way, Gatorade, ginger ale, and Saltines do not a balanced diet make, so I've got to start mixing it up.

A Painfully Detailed (Ha! Get It?) Description of my Egg Retrieval

First things first: 16 eggs, 12 fertilized naturally with IVF (no ICSI here.) I will find out my transfer date tomorrow.

At 6 AM yesterday (oh, who are we kidding, I was actually up tossing and turning starting at 5) I got up and headed over to my clinic. This was the first time I arrived right when they opened, and it was like a scene out of a play: the curtain opens outside the door to a fertility clinic. A dozen people stand outside in perfect silence, desperation and resignation written on their faces. None of the women look younger than 35 and no one smiles, either to themselves or to each other. If there is a sisterhood here, it is a sullen one. The door opens: wordlessly, everyone forms a single-file line and heads in.

Surreal. Anyway, once I finally got in, it was the usual pre-procedure drill: confirm my name and birthdate a few thousand times, put on a bracelet, sign the consent forms, change into the hospital gowns and grippy socks. I did find that after all these injections, I no longer get squicked out about watching needles go into my skin, so I watched the whole time as the nurse put in my IV (and saw the giant bruise start to form that I just knew was going to happen.) I took a single pill of Ativan and she had me wait on a gurney and gave me a magazine at random - the issue of Lucky where Elizabeth Banks describes her struggle to get pregnant and eventual decision to use a gestational carrier. I read the article and tried to think to myself, this is okay, Elizabeth Banks did this, you can do it too.

But as much as I'd like to just keep asking myself WWEBD (What Would Elizabeth Banks Do?) and act accordingly, I bet that she had actual anesthesia for her retrieval. Which brings me to the part of my story where I was totally right to be concerned about the conscious sedation. Don't worry, I'm not experiencing post-anesthesia PTSD or anything, but damn, I felt everything. After getting my legs in place and draping over my personal region, the nurse hooked up my IV to a syringe of Fentanyl. She sat on my left side and took my left hand in hers and put her right hand on the syringe. She explained that she was going to hold my hand the whole time and push the Fentanyl with her other hand as needed - um, okay. It was weird to hold a stranger's hand, but then she pushed a small amount of the Fentanyl and it was like getting drunk very quickly: sure, I'll hold your hand, especially since you're buying this round! She started asking me questions about my siblings and I knew that she was just talking to me to distract me, but at that point my RE came into the room and I was glad to have something to focus on besides what was going on in my vagina. Which was: two burning pains from the local anesthetic as it was injected on either side. A prolonged and sharp digging sensation as he worked on my right ovary and then the same thing on the left. The really bad part was when he said "so, in order to get these last two eggs, I'm going to have to puncture the endometrioma. Okay?" I said okay, and then as he stabbed it, I squeezed the nurse's hand really tightly in spite of myself. It felt like, well, being stabbed! I was still with it enough to feel him do the mock transfer (which appeared to be just putting a catheter into my uterus and wiggling it around for a second under ultrasound), but after that I have no memory until I was laying on a gurney in the recovery room with an IV of antibiotics going into me. I don't remember whether I walked to that gurney, which honestly bothers me more than the memory of the pain itself - I really don't like knowing that I was walking and talking with no knowledge of what I said or did.

This is the other strange thing: once I was in recovery, the pain began to really mount. It started around a 1 or a 2 on a scale of 10, but kept building until I described it to the nurse as more like a 4-5. I was starting to panic because they were saying things like "maybe you'll be out of here in a few minutes" and I didn't know where this was going to level out and didn't want to find out the hard way, and the nurse said the only thing she could do was push more Fentanyl, but that would delay our departure which apparently they didn't want to do. I mean, it kind of seems to me like I shouldn't have had to bring my own drugs to the clinic, but eventually they settled on having me take some of the Percocet that I had been given after my surgery in October that I brought with me just in case (once a Girl Scout, always a Girl Scout) which then made me predictably nauseous - somehow we managed to drive home with the help of a pillow cushioning my belly from the seatbelt and one of those kidney-shaped containers in case I ralphed in the car.

I spent the rest of the day in bed trying to figure out whether the pain or the nausea was bothering me more, though the winner became pretty clear when I started repeatedly throwing up.  I finally got some soup in me around 8 PM and took my doxycycline and medrol around 10 when it seemed like things were going to stay down. I slept okay last night and am back at work today with a bottle of extra-strength Tylenol and a heating pad strapped discreetly beneath my sweater - in an ideal world, I'd have taken today off, but I just don't have the time. Besides, it's better than waiting around at home obsessing about the 12 embryos in a lab across town that contain genetic material from both me and Harry (a very weird concept, but frankly, I'm thrilled that they have a babysitter today because I am just not up to childcare in my current state.)

So that's where things stand - if you've been reading some of my earlier posts, you will know that I harbor no small amount of anger about having to undergo the physical pain and trauma of IVF. Now that retrieval is behind me, I do feel some relief, although as I get farther and farther away from the pharmacologically induced relaxation of yesterday's sedatives, I am seriously considering changing clinics for our next attempt. Other bloggers have described how nice it was to feel the drugs knock them into unconsciousness before any needles were taken to their ladyparts, and I've seen lots of terms like "Operating Room" and "Anesthesiologist" thrown around. My retrieval was in a slightly-larger-than-usual exam room - definitely not an OR. And the highly scientific hand-squeezing technique that the nurse used is, I'm sorry, no substitute for a heart monitor or an EEG to measure pain response. I had real surgery recently, and this was no surgery. This was an in-office procedure that is routine for their staff but not to the patient, and while many women may feel that this is an acceptable level of pain to achieve their dream of becoming a mother (or simply don't realize that they have a choice), I just don't agree. I'm not going to make any decisions now, but Harry and I will have a big talk about our next steps at some point.

On another note, I have to send some love out to AJ, who had her retrieval yesterday too; to Emily, who is planning out the next stage of her journey after getting this week's IUI results; and to Blondie, who is currently incubating the cutest lil' blastocyst. I hope that all of you get good news soon.

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. :-)