IVF in July/August

We had to wait three months for the appointment, and then an additional 70 minutes in the waiting room, but the Professor has now officially granted us permission to begin IVF. The meeting itself was a bit pointless and anti-climactic, as it was basically an appointment to make another appointment for the end of May, once my insurance has approved IVF. Over here, six egg retrievals and all subsequent fresh and frozen transfers are covered for all female patients under 43 years, after three unsuccessful IUIs. I am so thankful for this.

The midwife talked to us about the process, and mentioned that I can choose between twilight anesthesia and local anesthetic for the egg retrieval. When describing twilight anesthesia to me, she said “so during the procedure you are in pain and are telling us, and asking for help, but afterwards when we ask you if you were in pain, you have no memory of being in pain”. At this description I visible paled and started to panic, my husband trying to comfort me. In this panicked state, it didn’t even occur to me to confirm that they do actually give their patients pain-relief during twilight anesthesia. However, as English is her third or forth language, I am going to put it down to a translation error.

The professor said that our main infertility issues are partly blocked tubes, spontaneous premature ovulation during IUI, thin endometrial lining, and a slightly lower sperm count. Happily, these are all issues that are likely to be circumvented by IVF.

Plus, I get to use a new orifice for medication delivery – over here in Europe, the IVF patients inhale their lupron through a nasal spray four times a day. Fewer injections are just fine with me.

I am on the long protocol. When I get my period in June, I go on the pill for 17-40 days, overlap the suppression medication, then begin Menopur injections. If it all goes to plan, we’ll know the result of our first IVF in August. If that doesn’t work, we’ll have a break cycle and then, if we can, a frozen cycle in October.

IUI#4 14DPO Not Pregnant

Not Pregnant. Those were the words that greeted me this morning. I’ve bought a bunch of digital pregnancy tests from eBay. I much prefer the definitive answer. No examining the strip under a bright light, or scooping it out of the bin to see if a line has subsequently appeared. No room for doubt or error. Not Pregnant.

The worst day of this cycle was the day of the trigger, when I discovered that I had spontaneously started to ovulate while my lining was too thin. I “knew” then that this cycle would be no different from the others. My belly full of holes was for nothing, and I even had to inject myself with the drugs for the first time, as my husband was due home late that night. I demolished an entire jar of Nutella.

This was our last IUI, which means that the next time my belly is attacked with needles, it will be for IVF. We will have a 40% success rate instead of 10%. For the first time, my adhesions and blockages will not interfere. If nothing else, we might even be able to see the result of our combined genetic material, even if it is just a small blob of cells.

Consultation appointment in two weeks, procedure in July/August.

IUI#4 CD13

This morning it looking like things were moving along well, with a "beautiful" lining of 6.5 and a follicle at 16.2 mm. However, the phone call this afternoon announced that I would not be coming in for another ultrasound tomorrow, but for my IUI. "Already?" I said. "Already", they confirmed. My HCG Pregnyl shot tonight at 8pm, and then the IUI tomorrow at 12:30.

Now I know my ovulation date, I can take a look at how my response stacks up against the other IUIs. And my endometrium measurements fit right over the other ones. No matter if I ovulate at day 9 or day 16, my lining is always around 7 mm, one standard deviation below my clinic's average of 8.7 mm ± 1.59. My lining is a consistent under-achiever.

IUI#4 CD10

I was able to check in on my ovaries again this morning. My lining is looking good at 5.5 mm (triple stripe), there are no large follicles on my right ovary, and my left ovary has a single follicle at 12.1 mm. This is good, if we can take things nice and slow, there will hopefully be time for my lining to thicken up a bit before we trigger. My estrogen was only 80 on Monday (CD8), so everything is just cruising along gently, which is fine with me. I'm guessing the IUI will happen around CD15. Now I just wait for the nurse to call and tell me when to come back again. (Edit: E of 121).

IUI#4 CD8

I woke up very excited this morning. I love the chance to spy in on my ovaries and see exactly what they are up to. I had my first ultrasound of the cycle today, and everything looks great. My lining is already at 4.4 mm (red dotted line) with a triple stripe pattern, and for once my follicles are not racing ahead. I have a sub-dominant follicle on my right ovary at 7.1 mm, and a dominant follicle on my left ovary at 10.1 mm (red unbroken line). It looks like 37 units of Menopur per day is a good dose for me. Looking at this, I guess that we'll probably do the IUI around Sunday on day 14 - must more respectable than day 9 with the first injectables attempt.

IUI#4 CD3

Yesterday was the first day of Menopur shots. Considering that I ovulated on day 9 last time, they have cut my dose in half. So I take half an ampule each night, keeping the other half in the fridge until the next night. My husband is doing a wonderful job mixing everything together and giving me the injections.

Protocol:
CD2-CD7: ~37.5 IU Menopur
CD8: Ultrasound and bloodwork - Menopur dose as advised
CD9-17: Possible ultrasounds and bloodwork - Menopur dose as advised

It has now been two years since I started ovulating again after eleven years of hormonal contraception. Twenty six cycles, twenty six ovulations, twenty six thermal shifts. Fertility friend tells me that my second year-long VIP membership will expire next month. Do I sign up for another twelve months?

IUI#4 CD1

Our insurance approved the injectables for IUI#4, so we start with low doses of Menipur tomorrow. I go in next week for my first scan.

It has now been over five months since my laparoscopy, and the surgeon said that the adhesions start to grow back after six months. After this cycle, we will not be attempting any more IUIs, and will start preparing for IVF.

Our lives have really settled down recently, we both have stable jobs, and we have a spare room that would look perfect as a nursery. For so long I have been able to tell myself that it wasn't really the bset time to have a child anyway, but now I think that this December might be an excellent month for us. I am very glad, however, that we started trying two years ago when our lives were all over the place, so we're not starting at square one today.

Yes, I would like a child, please.

After some serious contemplation, I have decided that, yes, I really truly want to raise a child with my husband. These are the sort of events that I would love to experience in my life:

• Dressing our baby up like a bear.
  
• Seeing them asleep in my arms.
  
• Helping them assemble a rock/stick/leaf/shell/etc collection.
  
• Make them laugh.
  
• Reading to them and seeing their imagination soar.
  
• Listening in awe as they speak a second language.
  
• Seeing their faces as they discover new places.
  
• Creating new family traditions together.
  
• Involving them in making family decisions.
  
• Helping them figure out how the world works.
  
• Doing my best to answer the question "why?".
  
• Making a train-shaped birthday cake.
  
• Watching the private world that they create with other children.
  
• Learning from their unique insight and experiences.
  
• Watching their personality develop into a whole new person.

Even if we do have a child, there is no guarantee that we will experience any of these moments. How do you decide to welcome a new person into your home that you have never met? How do you decide that the benefits outweigh the risks? Mel wrote about this leap into darkness a few days ago:

I think it’s brave to put your heart out there, to want something so badly, to allow your entire being to get wrapped up in the potential life of another person. If we make that leap to love a partner or family member or friend, we do so knowing that person, having met them, knowing our compatibility or history. But when we put our entire heart into the idea of a child, we do that bravely. Without answers or information or sometimes even a true understanding of what it will be like to parent.

With this confirmed desire, I called the fertility clinic to schedule our next IUI. However, I learned that this cycle needs to be pre-approved by our health insurance, which means a delay of at least another month. So more waiting and day dreaming for me.

Will we be happier with a child?

Having children is a life changing event. Suddenly, there will be this new person in our family. My husband asked me to take a moment to stop and really think about if I truly want a child, or if I am just getting mission-orientated.

Julie addressed the question of "is it worth it?", and one commenter wrote:

This one is tough for me, too. And it's tough because, as much as I truly, madly, deeply love my children, I now realize how much of my own life--a life I really loved--I gave up in being a parent. I miss that life. And I sometimes think that if I didn't get the diagnosis "Infertile," if it had felt like a free choice and not a need to prove something to myself (I'm classic overachiever; having children was the one thing I couldn't 'get right'), maybe I would have made the decision to be childless. And maybe I would have been equally happy, or even happier. That's a hard truth to face.

So I am taking a few days to line up the pros and the cons of bringing a child into our family. Here are the most commonly cited reasons for having children or being childfree:

Reasons to have children	Reasons to be childfree
An additional way to express love for spouse	Less global overpopulation
Increased closeness with friends with children	More energy and fewer illnesses
More fulfillment and meaning to life	More freedom and spontaneity
The experience of parenthood	More money
The opportunity to provide and receive love	More privacy
The pleasure and pride of raising children	More sleep
To develop personally by interacting with children	More time for hobbies
To have a relationship with children	More time to develop career
To transmit ones own ideals and beliefs	More time with adult friends
	More time with spouse
	No problems associated with children

I also ploughed through the literature on happiness, marital satisfaction, and freedom in parents, the involuntary childless, and the voluntarily childfree. It appears that parents and voluntarily childfree couples are as happy as each other, and are both happier than the involuntary childless. Some studies suggest that marital satisfaction may be slightly lower for parents than for voluntarily childfree couples. Mothers state that they have less relaxation, independence, and freedom than voluntary childfree couples.

Outcome	Sex	Parents	Involuntarily childless	Voluntarily childfree	Ref
Well-being	M	47.8	not included	45.0	1
Life satisfaction	both		not included	3.5	2
Global well-being (1-9)	F	6.44	6.28	7.06	3
My life is disappointing (1) to rewarding (7)	F	5.42	4.68	5.18	3
Satisfaction with personal success (1-9)	F	5.94	5.50	6.37	3
Life satisfaction	both	23.7	not included	25.2	4
Happiness	both	0 (a)	-0.17	-0.14	5
		-0.18 (b)
Depression	both	0 (a) 0.05 (b)	0.09	0.07	5
Life satisfaction	both	0 (a) -0.30 (b)	-0.46	-0.22	5
Depression	F	1.68	1.73	not included	6
Life satisfaction	F	3.18	2.89	not included	6
Marital satisfaction	M	33.0	not included	31.7	1
Marital satisfaction	both	5.95	not included	6.00	7
Positive marital interactions	both	3.49	not included	4.32	7
Unhappy with marriage	both	7.4%	not included	0%	8
Marital satisfaction (1-5.7)	both	4.50	not included	4.75	2
Satisfaction with marriage (1-9)	F	6.96	7.84	7.37	3
Marital satisfaction	both	91.9	not included	93.6	4
Marital satisfaction (6-45)	F	38.2	not included	40.0	9
Marital satisfaction (6-45)	M	37.6	not included	38.8	9
Amount of relaxation in life (1-9)	F	4.26	5.81	5.28	3
Amount of independence and freedom (1-9)	F	4.90	6.69	6.46	3
Amount of friendship and love in life (1-9)	F	6.72	7.43	6.90	3
Satisfied with childbearing decision	both	3.87	not included	3.73	2

(a) = close ties to their adult children (standardized to 0)
(b) = distant ties to their adult children


1. Magarick, RH & Brown, RA. 1981. Social and emotional aspects of voluntary childlessness in vasectomized childless men. J. biosoc. Sci.13, 157-167
2. Burman, B & de Anda, D. 1986. Parenthood or Nonparenthood: A Comparison of Intentional Families. Lifestyles: A Journal of Changing Patterns. 8, 2, pp. 69-84
3. Callan, VJ. 1987. The Personal and Marital Adjustment of Mothers and of Voluntarily and Involuntarily Childless Wives. Journal of Marriage and Family, Vol. 49, No. 4, pp. 847-856
4. Somers, MD. 1993. A Comparison of Voluntarily Childfree Adults and Parents. Journal of Marriage and Family, 55, pp. 643-650
5. Connidis, Arnet I., McMullin, JA. 1993. To have or have not: Parent status and the subjective well-being of older men and women. The Gerontologist; 33, 5; pp. 630-640
6. Schwerdtfeger, Kami L. and Shreffler, Karina M.(2009) 'Trauma of Pregnancy Loss and Infertility Among Mothers and Involuntarily Childless Women in the United States', Journal of Loss and Trauma, 14: 3, 211 — 227
7. Feldman, H. 1981. A Comparison of Intentional Parents and Intentionally Childless Couples Journal of Marriage and Family, Vol. 43, No. 3, pp. 593-600
8. Ramu, GN. 1984. Family Background and Perceived Marital Happiness: A Comparison of Voluntary Childless Couples and Parents The Canadian Journal of Sociology / Cahiers canadiens de sociologie, Vol. 9, No. 1, pp. 47-67
9. Lawrence, E, Rothman, AD, Cobb, RJ, Rothman, MT, Bradbury, TN
2008. Marital satisfaction across the transition to parenthood. Journal of Family Psychology. Vol 22(1), Feb 2008, 41-50.

Not pregnant, but alive

I caught two trains in Belgium today to get to the fertility clinic - one at 7:30, the other at 9:30. On my way back, the train was travelling very slowly, and I noticed several men in bright yellow vests walking along the other tracks. As it was snowing quite heavily, I thought nothing of it.

Then on I saw the news item "25 dead in train crash outside Brussels" flash across my desktop. My husband was also due to catch a train that morning, and I had not heard from him since I left the house. My hands were shaking as I called his work, and I was so happy to hear his voice on the other end. He had not heard about the crash, and once I told him the news, he was so glad that I was okay, too.

While I was on the phone with him, I got the call from the clinic telling me that I was not pregnant, and they suggest one last shot at IUI with injectable Menopur.

But all in all, I feel extremely lucky today.

Endometrium thickness

Does clomid really thin out the lining more than injectables? The literature says that it only does this when taken on its own, but not when supplemented with estrogen.
From Dickey and Holtkamp, Human Reproduction Update 1996, Vol. 2, No. 6 pp. 483–506

Does endometrium thickness affect IUI outcome? Yes, significantly (p < 0.01). IUI birth rates per cycle for endometrium thickness at time of HCG trigger:

Regimen	6 mm or less	6 to 8 mm	8 mm or greater
Clomid	0%	7.0%	14.0%

From Dickey and Holtkamp, Human Reproduction Update 1996, Vol. 2, No. 6 pp. 483–506

At my scan yesterday (CD14) my endometrium thickness was 6.9 and my dominant follicle measured 19.6. We triggered last night, and the IUI is today. Looking over my last three cycles, I analysed my data and saw that, while Menopur thickened my lining more quickly, I also ovulated earlier at CD9. For all three cycles, my lining is around the same thickness right before ovulation, and it is far below average. At least this time it's above 6, which means we have a shot.

IUI#3 CD12

I do love having my cycles monitored. I love graphs and tracking my numbers and knowing exactly what is happening. I like knowing what my ovaries are up to and how everything is progressing.

However, our clinic is not very empowering in that respect. They never tell me my hormone levels, and I have to quickly memories my ultrasound numbers as they appear on the screen. Today I asked the midwife what the procedure is, if we decide to move onto IVF. Her response was "you do not decide to move onto IVF, the professor will decide." She went on the explain that for IVF to be covered by the Belgian health care system, patients generally must try three IUIs first.

We are lucky to live in one of the few countries that provides six cycles of IVF to most residents. It pays for this cost by mandating that many of these must be single embryo transfers, which decreases the number of multiples born, and thus lowers the higher costs associated with multiples. The savings made on decreased newborn intensive care usage pays for the cost of providing IVF.

IVF coverage in Belgium:

age	IVF 1 to 2	IVF 3 to 6
Less than 36 years	single embryo transfer	two embryo transfer
36 to 39 years	two embryo transfer	three embryo transfer
More than 39 years	three embryo transfer	three embryo transfer

As for me, my dominant left follicle is still only at 13 mm, and my lining is still only 5.3 mm. Moving very slowly this time around. I'm guessing the IUI might be on Wednesday? We shall see.

IUI#3 CD10

I was randomised to clomid this cycle (clomiphene citrate CD3 to CD7, estrogen CD8 to CD12), and as I had some at home that meant that I didn't have to go into the clinic until today. The midwife who was taking my blood looked so young that I was worried that she would be incompetent. I think however the problem was that I am getting old, because she was fabulous. In fact, she coaxed out so much of my blood that I didn't realise that I was continuing to leave little drops of the stuff over the chair and floor of the waiting room. I was so embarrassed to have to get one of the midwives to clean it up for me. Still, better that than leaving human blood around the place.

My follicles seem to be ripening more slowly this time around. Last CD10 with clomid my dominant follicle was at 16 mm, but this time around it is only 11.7 mm. This is great, because I need time for my endometrial lining to thicken up. My lining is only 3.7 mm, the thinnest it has ever been at CD10 - it's gone from 7.6 mm (IUI#1 Menopur) to 4.8 mm (IUI#2 Clomid) to 3.7 mm (IUI#3 Clomid). I have been reading through the literature, and it really needs to be at least 7 mm on the day of the HCG trigger for a good chance of success.

The good news is that the dominant follicle is on my left ovary with the good tube. I should know more when I hear from the midwife this afternoon, but my guess is that I will have another scan in two days (CD12) and that the IUI will be on Monday (CD15).

IUI#3

New year, new IUI cycle. After a lovely vacation and break, it will soon be time to get back on the Assisted Reproductive Technology horse. Yes, I am still involved in the clinical trial, and yes, we have two more IUIs planned before we move on. The plan is:

February: IUI #3
March: IUI #4
April: Break and vacation
May/June: IVF #1
July: Break
August/September: FET/IVF#2

By this time, the theoretical success rate will be over 50%, and hopefully we will be part of that proportion.

Otherwise, we are just taking things month by month. We do not make any long term plans that we would have to change in the event of pregnancy. I try to schedule as many meetings at work in the afternoon, just in case I have to spend the morning at the fertility clinic. My calendar is divided into 28-day increments. I take my daily pre-natal tablet, as I have been doing for the past two years.

As long my husband and I have each other, we will be okay. For the moment, I am his baby and he takes care of me. He makes sure that I am taking care of myself, and that I have plenty of indulgences.