IVF#1: Post-failure consultation

We had a fabulous consultation yesterday. We left the appointment feeling like our clinic has a great understanding of IVF and is really tweaking out next cycle to give us the best chance of success. These are some of the answers to our questions:

FET cycle
• How fragmented was our 6-cell embryo at freeze?
They gave it a score of 2 (with 0 best and 6 worst). The symmetry was 1 (with 0 best and 2 worst)
• What are the chances that this embryo will survive the thaw?

There is a 60% chance that it will survive the thaw, and then a 10% chance it will result in a live birth. By law, I must use up all my frozen embryos if I want my next fresh cycle to be funded by health insurance. They quickly signed me up for a clinical trial of Menopur-versus-no stimulation for my FET cycle. I am in the Menopur arm, but I can opt-out and just go the no stimulation with monitoring route instead. I am not sure which option I will take.

Next fresh cycle
• Given my poor response, and that no embryo reached the 8-cell stage, what are our chances of success in future fresh cycles?

At my clinic, 9 eggs is not a poor response - they only aim for 10 eggs retrieved. I guess as 6 fresh cycles are funded, they prefer to have fewer patients with OHSS. They said 6-cell and 7-cell is not that far off from 8-cell, and that we have a very good chance of success in future fresh cycles, especially with a change of drug regime (see below).
o Does our history of a chemical pregnancy and miscarriage influence this?

One chemical and one miscarriage, sadly, falls within the 'normal' range and doesn't tell us anything.
• Will I be on a different drug regime next time around?
Absolutely. My LH was too high throughout the whole cycle, indicating that I was not properly suppressed. He even asked me if I had trouble using the nasal spray. So instead of Suprefact nasal spray for suppression, I will be taking an injectable lupron-like drug instead. Then, instead of urine-derived Menopur I will be taking the recombinant Gonal-F. He said that in order to reduce costs, they put first-time IVFers on the cheaper Menopur, but then after that keep them on Gonal-F, which has a better quality control and is easier for the patient to use.

• How many eggs should we transfer next time?

By law I am now permitted to transfer two embryos, but I am leaning towards elective single embryo transfer. The increased risks associated with twins makes me uncomfortable.

• Can we squeeze in another fresh cycle before New Year's?

Probably. I need to ask them if they want me to have a break cycle after my Menopur-FET.

Donor embryos
• Can you tell us about your frozen embryo program?

They were very unwilling to talk with us about this program. They said that they usually suggest it as a last resort, and no on has ever asked so early on in the process. The process is completely closed, even if the child turns 18, and even if the child requires a bone-marrow transfer.
o Does the six month waiting period apply for every frozen donor embryo transfer?

No. It takes six months for the psychological tests, and after that, we are permitted a 'virtually unlimited' number of donor embryos.
o What criteria do you use to match couples with embryos?

I couldn't get much information on this. From the web, it appears that no matching is conducted (I'm not sure about blood-type).
• Can we sign up for donor embryos now while still attempting our own cycles?

Not yet. They suggest we try a few more time with our own gametes first.

• Will they transfer in donor embryos shipped from abroad?

This question really confused the guy. To clarify, I said, if we had a frozen embryo shipped from the Czech Republic (thinking of Reprofit's bank of cheapish embryos), would you conduct the transfer? He then looked really confused, asking me if I wanted a Czech baby? I laughed, and said, no, we just want one good embryo. We don't care where from. My husband said that we'd even be happy to take a baby if they have any of those laying around. The poor guy just looked more confused and I had to tell him that my husband was joking.

So that's that. Most of my questions answered, and a shiny new drug regime waiting for me for our next fresh IVF cycle. I feel hopeful and happy.

Now it's off to the UK for a week!

So. Surgery it is.

We had our second infertility meeting yesterday. It is mostly good news. All our genetic tests came back normal, which means that we both have the right number of chromosomes, and aren't carriers for any major monogenic diseases. Our blood hormones also look normal. We found out that my husband's sperm morphology is 4%-7%, which is sub-normal, but not really that bad.

Thanks to Fertility Friend, I know that we have had well-timed intercourse for over 14 ovulatory cycles with no pregnancy.

So the next suspected culprit is endometriosis on my side. This is tricky to diagnose externally. I never suspected this, though when I think back my periods do seem to be getting worse with time since I went off the pill. So the professor recommends a laparoscopy/hysteroscopy.

While it is keyhole surgery, it is still surgery. General anesthetic, filling my abdomen and uterus full of gas, and three keyhole cuts - one for the camera, and two for the robot arms. They say that in 50% of cases like ours, they find mild endometriosis, which they repair with a laser during the same operation. After treatment, they move onto IUIs and notice a doubling in success rates compared to women who do not have their endometriosis fixed. We will then have a 10-20% chance of success for the first IUI cycle.

So the expected timeline would be something like:
October: Hysteroscopy
November: Stimulated IUI #1
December: Stimulated IUI #2
January: Stimulated IUI #3
February: Meeting to discuss options

Now I am waiting for the nurse to call me to schedule my first ever operation. I am quite worried and nervous. They say there is <1% chance of complications and that they do around 10 of these operations a week, but I am still frightened of catheters and drips and anesthetic and incisions. Still, I suppose pregnancy and childbirth is no walk in the park either, so I might as well start to get used to strange things happening to my uterus.

I am not looking forward to the pain.

Internal Ultrasound

Yesterday I had my internal ultrasound. Again, it was at the gynaecology ward of the hospital, so I was surrounded by large bellies and excited couples. I imagine this would be very difficult for many.

It was a little bit disconcerting, sitting there half naked with my legs hoisted up to the ceiling while the doctor was asking me about my medical history. It also didn’t help that the technician was new and couldn’t find my uterus or my ovaries. For a while there I was convinced I didn’t even have a uterus, which had me shaking with nerves on the cold chair.

But in the end, my uterus and my ovaries passed this superficial test. They exist, there is no endometriosis visible, and my left ovary has a bunch of immature follicles that are competing for dominance on this CD6.

I asked the doctor if I could get a copy of the images. He looked completely baffled. He said “why, to show your family?”, like I was going to post my grandmother a photo of my empty uterus. So I just told him that I liked to keep a copy of all my medical records. He didn’t give me any images, but I did manage to wrangle a copy of the report.

As for the results of all our other tests? We do not find out until August 12. I called up the Fertility Centre and they only discuss the results in person, during the consultation appointment. They do not release the results before then.

This is very frustrating. I like to do my own research on the implications of the data, but instead we have a single meeting with the head of the centre to discuss strategy where he is holding all the cards. I know that all the information we need about our own bodily fluids is just sitting in a file someone, and I am unable to access it.

So more waiting and waiting for us.

My insides:
Uterus:
Position: ante
Dimensions: L:53 A-P:26 T:32

Endometrium:
Imaging: clear division
Structure: intact

Right Ovary
Imaging: visible
Morphology: Normal
Limitation: Regular
Size: 31
x 23
x 18
Volume 6.7

Left Ovary:
Imaging: visible
Morphology: Normal
Limitation: Regular
Size: 30
x 30
x 17
Volume 8.0

First infertility appointment

It's a good thing that am very happy about my life, because it turns out the infertility center works out of the gynecological department in the hospital. So we watched many pregnant bellies walk back and forth while we waited.

We were then interviewed by a younger woman about our medical histories. She did raise her eyes at my numerous graphs and statistics. She asked me for how long I had had a "baby wish", and my husband wryly noted that she did not ask him the same question when it was his turn. I thought I had prepared quite well, but when she asked me how often we had sex per month, that was not a ready figure that I had with me. I pulled out Fertility Friend's intercourse analyzer of my fertile periods over the past 12 months, and she asked "and outside of these times, you do not have sex?" I denied this statement, but now I am sure that she thinks we are celibate for 24 days out of the month.

Then suddenly she said to me, "and now we shall do an internal examination", and made some sort of gesture with her hands. Now? Did she want me to take off my skirt this moment? Yes, she did. She did not ask my husband to leave the room. She did not walk out of the room or give me a gown. She merely stood there, waiting for me to undress in front of her. I felt very shy, and removed my skirt without even thinking to remove my undies. It was only when I sat down on the paper that I realised my mistake. I removed my undies, hoisted my legs up on the stirrups, and in a few seconds she was in and out with a cervix spear.

This was all a little shocking for me. Why is it the act of undressing feels more weird than actually being naked? And what is wrong with draping a bit of fabric over the top to pretend otherwise?

Once I was dressed again, she called in the doctor came in. He looked at my temperature charts and told me that these were the best charts that he had ever seen, which was to be expected, he said, as I was a scientist. Usually, he said, they ask women to track two or three cycles, never... fourteen. I replied that you get a much better standard deviation with an increased N.

He said that the plan was to test my blood at CD21 and CD3 and do a basic internal ultrasound. In the meantime, my husband would be tested for "male factor" (he dislikes being reduced to that phrase) and if that came up normal, they would conduct further tests on me. They would also begin genetic tests immediately, as they take two months for the results to come through.

Today was my CD21 blood test, then I have my CD3 blood test, and then I come back for my ultrasound in a month. We meet with the doctor on August 12 to discuss our next strategy. I tried to ask my questions about donor gametes and embryos, but he said it was much too early for those sorts of questions. But now we are moving forward, and I feel accomplished. In 70 days we should have plenty to talk about.