Shooting Up

I could be way off here, but I find this one of the most unusual and perhaps even fascinating aspects of the IVF cycle.  The injections...

Currently, my doctor has me following the Microdose Flare Protocol.  There are a number of different drug regimens out there, each differing slightly to accommodate the woman's unique infertility profile.  The Microdose Flare Protocol is a pretty aggressive course.  It is often cited as the "poor responder" treatment; you give it to women once they've already proven to have a hard time making eggs during an IVF cycle.  Why give it to me on our first try?  Take a look at this excellent chart below:

This shows AMH (Anti-Mullerian Hormone) levels for women over time.  Testing AMH levels can gauge the extent to which someone's biological clock is ticking away faster than the woman next to her.    The hormone being tested here is excreted by the small follicles in the ovaries (the little pockets where the eggs grow), and it gives the doctor an idea of just how many eggs are in reserve.  If you follow the solid curve on this graph, you'll see the average AMH levels for any particular age.  For someone my age, it should be about 20.  Mine is 7.2, which is right around the 25th percentile.  Another way to look at this chart is that I have the egg reserve of the average 39 year old.  This means I'm 30% less likely to produce enough eggs in this cycle to be successful.  Hence, BE AGGRESSIVE!  B-E AGGRESSIVE!

Right now, I'm taking three injections a day.  I use insulin needles and inject them subcutaneously (just below the skin).  It really doesn't hurt at all.  I find it way more painful to play with Harper for five minutes.

Lupron (2x/day) - This stimulates my pituitary gland to produce more of its own luteinizing hormone (LH) and follicle stimulating hormone (FSH).

Gonal F (1/day) - Synthetic version of FSH.  This one has to be mixed daily.  I pretend I'm a chemist.  I might get some of those sexy goggles and a white coat just for this ritual.

Low Dose HCG (1/day) - Synthetic version of LH.  This one is premixed, but they want me to combine it with the Gonal F in a single syringe.  It's nice because there's only one tiny prick for two drugs, but it sucks because getting both of these combined takes roughly twelve steps (no hyperbole here), and by my way of thinking, that's twelve unique opportunities to screw up.  (I wanted to film this unbelievably complex series of actions, but Jake assures me this would be weird.)

All this is to push my eggs to go bananas right now.  I went in for my first monitoring appointment today, and it seems like everything is going relatively smoothly.  They were able to see 9 follicles on the ultrasound, though they were very small, and my estradiol level was 85.  Trying to figure out whether that's good or not is really confusing.  I'll get back to you guys on that one.  Keep your fingers crossed, y'all!

Snowquester

After confirming ovulation last week, we were instructed to place a phone order with Freedom Fertility.  Tuesday afternoon, a large box arrived, overflowing with syringes, needles, glass bottles, alcohol swabs, even our very own biohazard "sharps" container.  Talk about playing doctor!  All that was left to do was stick a few of the meds in the fridge and wait for my period to arrive.  As a snowstorm started rumbling up the Shenandoah Valley, I snuggled under the covers and watched YouTube videos of calm, smiling women stabbing themselves in the belly for the chance at a child.  I prayed for strength.

When we woke up the next morning (a little late, as it was a highly anticipated snow day) we noticed that our power was out.  Oh well, we thought.  We'll just have to wait a while to get started on our day. We rescued the precious Leuprolide and HCG from the fridge and buried them in a plastic bag in the snow.  We hung out for a while, reading, knitting, worrying about the food in our fridge/freezer, then decided to go find someplace nearby serving hot food to cheer us up.  A dismal drive around town revealed that absolutely everywhere was out of power.  I was starting to get some major mood swings, partly from PMS but also greatly enhanced by the synthetic estrogen I've been taking.  Every few minutes I was hanging from the rafters silly, then collapsing in a pile of tears and self-pity.  Honestly, all I wanted was a warm bath and my heating pad.

The next morning, we woke up to an even colder, still dark apartment.  I was starting to lose it.  I had a paper due at class that night which I had lost an entire day to work on, my hair was a grease pit, and damn, my PMS was getting intense.  Bonnie called, wondering if we should meet for our injections lesson, in case my period didn't come until the weekend.  We agreed that would be best, but Jake had a meeting scheduled with a professor, and I hated that I would have to just drive up another day to get the baseline data done.  Just like that, Aunt Flo showed up, and Jake's professor canceled their meeting.  Was our luck finally changing?!  We drove up to Charlottesville in separate cars, played with some needles at Bonnie's desk until I felt confident I could do it, and had what essentially felt like a drive-by ultrasound.  We were instructed to start our shots the next morning.  Jake drove back, assuring me we would have power by the time I got back.  I just couldn't believe I was going to class at once so filthy and so unprepared.

Of course, the power wasn't on when I returned home at 10:30 pm.  In fact, the electricity company had changed their projected time of repair to late the next night.  I started blubbering immediately.  I couldn't do my first set of injections in the dark.  I couldn't go to school in the morning still dirty.  I couldn't worry any more that the snow was keeping our meds the right temperature.  I couldn't face the rest of a night full of cramps without my heating pad.  I....just....couldn't.  I wanted a hotel room with a mini-fridge, or I was going to explode.  Since Jake's not suicidal, he found a room within seconds while I packed up our meds and a change of clothes.  The only place nearby that offered mini-fridges was about $20 more than the next cheapest place, but like I said, I was a woman on a mission.

This is when Lady Fortune decided to give the Lewises a break.  At check in, the staff hooked us up with an extra-small room at a special discount, HALF the price of the competitors without mini-fridges!  This room was auspiciously nicknamed "The Baby Room" by the staff.  I couldn't keep from grinning.  There were cookies and hot coffee in the lobby, next to a sign reminding us of the full breakfast buffet in the morning.  We sighed with deep satisfaction and ambled up to our room, congratulating ourselves on making such an excellent decision.  Though the room was small, it had everything we needed, and we enjoyed a warm, clean, relaxed night of sleep.

The next morning I self-administered my first injection (not a big deal at all, it turns out) and went to school.  A few hours later, I got a beautiful text message from Jake: the power was ON.  Hallelujah!

The "Told Ya So" Dance

When last we met, I was patiently for ovulation to occur.  Morning after morning, I kept getting turned down.  It was like the 9th grade Winter Dance all over again.  I called Bonnie, my new best friend IVF nurse, and asked her what would happen, hypothetically speaking, if I didn't ovulate this month at all.  She gently broke the news that it would be unwise for us to proceed with the planned drug protocol before confirming that I can ovulate on my own.  We would just have to wait until I did, maybe even a few months, if that's what it took.  Harumph.

So, the morning-stick-pee-sigh routine continued for another week, to no avail.  But meanwhile, my body was sending me some pretty unequivocal ovulation signs.  I won't get into the lady secrets here, but if you're interested, check out Taking Charge of Your Fertility.  I honestly consider it an indispensable owner's manual for anyone in possession of a vagina.  Now, what's a girl to do?  On the one hand, expensive technological tools are telling me that I didn't.  And yet natural methods are positively shouting that I did.  My girl Bonnie knew how to settle this one: a quick blood test to check for progesterone.  I was warned NOT to get it drawn at my local hospital, since they send out their samples and take several days, but was directed instead to nearby Staunton, 45 minutes away.

Luckily, the next day was one of Rockbridge County's famous snowless snow days.  I headed out to Staunton, surrendered my bodily fluids, and THEN was told that they would send it out late that night.  Grrr.  More waiting and anticipation.  Luckily, I knew where I could get a killer eggplant parmesan sandwich.  What?  That's totally related.

That night I could hardly sleep.  Did I?  Didn't I?  I DID!  Naw, you don't know crap.  The next morning's results couldn't come fast enough.  When I finally got a call from Charlottesville, I was shocked to hear that they did not yet have my results and were wondering when I was going to get that done.  WHA?!?  My disappointment turned to fury a few hours later when the lab in Staunton called to say that they had messed up my blood work, something about a red top instead of a gold top, or something completely asinine like that.  Needless to say, Bonnie had to talk me off the ledge.  We decided that, even though it's far, I better just hoof it up to Charlottesville to get my blood drawn right on site and not by idiots.  As a perk, I had a good excuse to skip a faculty meeting.

I had hoped that the results would be ready within two hours, before the office closed, but no such luck.  However, I got the call right when they opened the next morning.  I evidently shouted, "YES!" so loud into the phone that my friend Susan came over to hear the "apparently orgasmic news."

The March of the Pills

Our first appointment ALSO entailed getting started on our pre-IVF drug regimen.  They won't pull out the big guns until I start my next ovulatory period, but in the meantime, we're doing the following:

Both of us:

• Ciprofloxacin - preventative antibiotic.  Even minor infections can dramatically decrease the chances of IVF success.

Just me:

• Metronidazole - a special antibiotic JUST for the ole bat cave.  It comes with a three feet long applicator.  Fun.  Toilet acrobatics.
• Baby Aspirin - increase bloodflow to the uterus and make sure that future home is super comfy and lush.
• DHEA - a hormone supplement to support my production of estrogen and androgen.  Hopefully, this will make up for my egg reserves, which look like they ought to belong to an old lady.  All I know is I'm crying at especially poignant television commercials and breaking out with the acne of a 15 year old boy. 
• Estradiol - basically, a synthetic estrogen.  Again, geriatric eggs. 

We also got some blood work done, basically to make sure we're not teeming with chlamydia and ebola (news flash: we're not).  Jake has to get his swimmers tested ONCE AGAIN, presumably so the lab techs can point and laugh at those poor little guys one last time.  I had to get my AMH and thyroid levels tested again, too.  AMH came back confirming the above mention egg problem.  Thyroid came back a little weird, but subsequent blood work ruled out the need for synthetic thyroid medication.

I'm now off of birth control and waiting for ovulation.  They want me to ovulate at least once before we get going on this, so I've been drowsily peeing on those ovulation predictor sticks every morning for about two weeks.  The big O is a tad elusive this month, which figures, since I normally ovulate like clockwork.  Side note, did you know you can actually urinate onto plastic incorrectly?  Because I am a princess and like my toilet routine to be as high tech as possible, I splurged on the more expensive DIGITAL ovulation predictor kit on my way home from our appointment.  Twice, TWICE, the message that appeared in the window was a picture of an arrow pointing to a booklet.  Thaaaat's right.  This pretentious piece of plastic told me to go back and read the directions as to how I might more efficiently or perfectly pee onto it.  Since going through a box of those with no coveted "smiley face" result, I have downgraded to the less persnickety but far more inscrutable CVS brand.  Now, I'm supposed to compare the density and pigment of two pink lines.  Who has time for this nonsense?

On a more grim note, being off birth control has been tough these past two weeks.  Why was someone infertile taking birth control, you may ask?  Well, endometriosis is an inflammatory condition that is triggered by the ebb and flow of hormones.  Staying on the pill kept everything nice and quiet for the last year, and I was able to get by with only a few advil and a couple of hours on the heating pad a night.  Now, it's a mental battle every day just dragging myself out of bed.  The pain makes me sleepy and depressed, neither of which I have time for right now.  Come on, ovulation!

If I have a legitimate cycle this month, we'll get started on stim drugs as soon as my period arrives, possibly the beginning of March (cue ecstatic squealing and clapping). If not, we'll have to wait yet another month, which, though I know is nothing in the grand scheme of things, will totally bum me out.

Decisions, Decisions

Another thing we had to do at our appointment was sit down with our doctor and go over some very important decisions.  Some were easy to make.  Use ICSI?  Duh.  Freeze any leftover eggs?  Of course.    Assisted Hatching?  No need.  How many embryos to implant?  Hmmmm....

Okay, so for a woman of my age, here is the textbook recommendation.  If they are good quality embies, put back one.  If they are less than ideal, put back two.  The doctor explain that we could be more conservative and only put back one, regardless of quality, OR we could be more aggressive and put back two, regardless of quality.  With the former option, our chances of conceiving at all are lowered.  With the latter, our chance of conceiving twins as opposed to a singlet is 1 in 2.  Jake and I stared at each other awkwardly for a few minutes and debated in our usual, snarky, hyperbolic style.  "You know how I feel."  "No, you said you want to do what's best.  That's not clear here."  "I want to do what's most effective."  "Well, most effective isn't necessarily best.  Putting back five would be most effective!"  The doctor jumped in here to make sure we understood that nobody is cramming five embryos into a 30 year old.  She must have thought we were getting heated, because she handed over the form and told us to think about it over the next few weeks.  She was staying out of it.

However, with a few minutes left to ourselves while waiting for our next meeting with the IVF nurse, we knew our decision: the aggressive course, two embryos, high possibility for twins.  Essentially, we just know that we'll regret it terribly if we don't conceive after only putting back one.  From that moment on, we've been sort of deliriously giggling and joking about how crazy our future life with twins will be.  Jake's been peering, with wrinkled forehead, into his cramped backseat, trying to picture TWO carseats shoved into that tiny M3.  I've been mentally rehearsing trying to get from the parking garage in our future Dallas high-rise to the apartment door with two infants and a single sack of groceries.  When we talk about signing up for insurance at his law firm, he'll say, "Well, it's cheap for me but more expensive when I add you and..." "The TWINS," I finish.  And we both crack up and whimper a little simultaneously.

Dear Lord, one will REALLY suffice, but I promise I'll be gracious if you double our pleasure.

Good Things Come to Those Who Wait...and Wait

It's finally happening.  Nearly 5 years after we started trying to conceive, three years after we were told unequivocally that we had no chance of conceiving naturally, after two surgeries on my endometriosis, over a year after applying for our scholarship through INCIID, 6 months after we raised $3,000 for their organization, WE'RE FINALLY GETTING STARTED!!!!!!!!!

I want to again thank all of our family and friends who donated to INCIID on our behalf.  We are truly blessed with an incredible network of support.  Many couples navigate IVF in private, keeping the dates and details to themselves.  This makes a lot of sense, of course, because, when things go wrong, you don't want to have to share THAT news with everyone.  While this sort of privacy is appealing, we know our journey will be a slightly different one.  We've made this project a public one from the start, and you are all a part of this process.  You've a right to know what we're doing and how we're progressing.  Additionally, there are so many people whose faces screw up with concentration and wonder whenever I speak about this procedure in broad terms.  I have gotten the distinct impression that people are deeply curious about how this whole thing works.  If you're not in that camp, read no further.  But if you're like 90% of Americans and delight in all things voyeuristic, do enjoy.

INCIID matched us with the Reproductive Medicine and Surgery Center of Virginia, pretty much the most ideal match we could have had.  The clinic is only a little over an hour away, and we are familiar with our doctor since she did our official scholarship testing, as well as performed my most recent hysterosalpingogram (running fluid through the fallopian tubes under x-ray to see if they work) and laparoscopy (minimally invasive surgery to look around the pelvic region).  The latter had been performed last April for the purpose of cleaning up my endometrial adhesions and removing my blocked (and therefore toxic) fallopian tube.  She managed to open up the tube during surgery, doing exactly what two previous doctors had attempted to do three other times.  As a result, I have two working tubes and a new hero.

We had our first appointment on Tuesday, and it was a doozy!  Not difficult, just a lot of new information and decisions.  First, we did a practice run of the egg transfer, basically mapping out the size and shape and tilt of my uterus so there are no surprises on the day of the real thing.  The most amusing thing has to do with the ultrasound, which they move on the top of the belly to guide the catheter.  Now, between the surface of your skin and the uterus is your bladder, so they basically use it as a window to look through.  The bigger the window, the better the view, right?  Consequently, I was told to come with a full bladder.  The appointment was at three, so I made sure I used the restroom for the last time at lunch and spent the second half of the day sipping water.  By the time I got there I was rather uncomfortable and proudly told the nurse when asked, "Oh, yes.  VERY full bladder."  Well, apparently in egg transfer world, "full" has a totally different meaning.  They were looking for ready-to-burst; I was told to aim for twice as full on transfer day.  I wonder how many women have had "accidents" in that waiting room.

After the trial run transfer was a saline ultrasound, basically just a look-see around the uterus and ovaries to make sure there are no polyps or cysts that should be treated before we proceed.  My lady-junk got rave reviews, and the procedure was a breeze.  This ship is ready for boarding!

More on our first appointment in the next entry...

Break out the Cake and Champagne!

We reached our goal of $3500 in donations made to INCIID!!!!   Jake and I would like to send out the warmest of thanks to everyone who helped us to cross this finish line.  In particular, we'd like to commend Frankie's Mexican Restaurant for their special support in the month of June, as well as Jordan Swim of Vestals Foods for catering a beautiful six course dinner for our family and friends.

Our next step is to wait for a match between our needs and a clinic willing to donate its services. We'll keep you posted on the details here, so if you want to follow along, be sure to subscribe or bookmark.

We are overwhelmed with love and gratefulness.  Thank you, thank you, thank you!