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!

IVF#1: BFN

Well, it's official. After getting my period yesterday, I was expecting a zero on my beta today, and that's what I got: Not pregnant. I was quite sad yesterday, which worried my husband. He doesn't like seeing me so down, and just wants me to be happy. But I can tell that he will make a wonderful father, so I think it is appropriate for me to be disappointed that I won't get to see him in that role just yet.

The nurse told me that I could start my FET cycle right away if I wanted, but annoyingly I will be away for work next week, so it will have to wait another month. We are always waiting, aren't we?

We have my follow-up consultation with the head of the clinic on Thursday. To summarise this cycle: BCPs, Suprefact supression, 14 days 150u Menopur, 9 eggs retrieved, 7 mature, 7 fertilised (without ICSI), a Day 3 transfer of a 7-celled embryo, and a single 6-celled embryo frozen.

These are my questions for the Professor:

FET cycle
• How fragmented was our 6-cell embryo at freeze?
• What are the chances that this embryo will survive the thaw?

Next fresh cycle
• Given that no embryo reached the 8-cell stage, what are our chances of success in future fresh cycles?
    o Does our history of a chemical pregnancy and miscarriage influence this?
• Will I be on a different drug regime next time around?

Donor embryos
• Can you tell us about your frozen embryo program?
    o Does the six month waiting period apply for every frozen donor embryo transfer?
    o What criteria do you use to match couples with embryos?
• Can we sign up for donor embryos now while still attempting our own cycles?

Thank-you all for your support during this difficult process. Can you guys suggest any other questions that you think might be appropriate to ask?

Back on birth control.

As of today, I am back on the pill, and starting my first IVF cycle, using the standard long suppression protocol. However, my clinic is closed over the summer, so I don’t start Menopur injections until Thursday August 19, which is another seven weeks away.

I am so excited that the time has finally arrived for us to start this cycle. After two clomid IUIs and two injectable IUIs, I am hoping that the process will be familiar, though hopefully with a different outcome.

With my IUIs, I always spontaneously ovulated before my lining had time to thicken. Hopefully the supression from Suprefact will hold everything back a bit so my endometrium has time to mature, if not with a fresh cycle, then maybe a frozen cycle.

I am hoping that work is not too busy around that time, that I don’t have too many early morning meetings, and that there isn’t anything critical when I suddenly have to take a few days off. Once again, I will begin the familiar pattern of trips to the clinic in the morning, anxious afternoons waiting by the phone, and then injections in the evening.

I am still a bit nervous about the retrieval. The nurse assured me that they administer plenty of pain relief during the procedure, and even put a special note in my file that I can have a Xanax before the procedure. I took something like that before my laparoscopy, and it made the world of difference. Funnily enough, knowing that I won’t be feeling anxious before the procedure is enough in itself to substantially decrease my worries.

So it is time for me to make my way twice around the circle of birth control pills, and then the real adventure will start to begin.

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.

My answers to their questions

I want to end up with a diagnosis as soon as possible, so I am presenting them with anything in my history that might lead to a diagnosis.

Age: 29
Length of current relationship: 3 years
Trying to get pregnant: 12 months
Date of last menstrual period: 12 May
Age of first menstrual period: 13 years
Days of bleeding during period: 4 days then spotting for another 2 days
Length of periods: 26-32 days
PMS symptoms: Mild
Painful menses: Moderate cramping, one ibuprofen enough for relief
Bleeding between periods: No
Painful intercourse: No
Endometriosis diagnosis: No
IUD in the past: No
STIs: Tested in 2006, never detected
Did my mother take DES while pregnant: Nope, born after 1971
Breast discharge: No
Excessive hair growth: No
Previous pregnancies: None
Previous fertility treatments: None
Family history of disease: No
Sudden heat/Cold intolerance: No
Weight change: No
Hot baths: Warm baths every night
Exercise: 1 hour per week
Possible previous biochemical exposures: chance of sodium azide, ethidium bromide, Listeria, Shigella exposure
Drinks per week: 1-2 during follicular phase, 0 during luteal phase
Smoker: No
Contraceptive use: 1997-2003 BCP, 2003-2007 Implanon, Oct 07-Mar 08 BCP

Rubella vaccination: 1993
Pap smear: Feb 2008 - normal
Chicken pox: 1997
Blood type: O positive

Tests
LH tests: Positive result before ovulation
BBT: Thermal shift after ovulation, luteal phase ~ 14 days
Complete blood count: Normal
Serum ferritin: Normal
Thyroid stimulating hormone: Normal


Based on these answers, I think they should be able to rule out:
PCOS
Luteal-phase defect
Endometriosis
Pelvic inflammatory disease
Asherman's syndrom
Advanced maternal age



But there is still a possibility of:
Premature ovarian failure
Fallopian tube blockage
Cervival mucus defects
Fibroids, polyps
Pituitary tumour
Male Factor

Questions I plan to ask during our first fertility centre appointment

* What are your office hours?
* Who will be our point of contact?
* What specific tests would you recommend to diagnose our infertility?
* How long will it take to diagnose our problem?
* When can we begin treatment?
* Do you have ties to a donor egg/sperm/embryo program?
* Is an up-to-date laboratory located on site?
* What is your success rate with IUI and IVF in couples under 30?
* How many pregnancies performed at this clinic have resulted from IUI? IVF? Egg donation?
* Do you have a specialization for a certain type of treatment?
* How much will treatment cost? Does that include lab work, procedures and medications?
* What outside resources do you recommend?

This is why they are called cycles

Because they go around and around and around:



I am a scientist. I like to live in an evidence-based reality. I need numbers, charts, and graphs. I like to make quantitative comparisons. So now I have year's worth of patterns to analyse.




I seem to be ovulating. While my follicular phase is a little variable, my luteal phase seems to relatively long and consistent. But I don't know anything else about my body. Are my eggs getting lost? Are my tubes blocked? Is my mucus or lining sub-standard?

Once again, just waiting for a diagnosis.

Always waiting, waiting...

55 orange pills

It was quite a shock to take my pill this morning - not the automatic process that it has always been. This time, as I looked down and ran my fingers across my rows of pills, they didn't float off into infinity like they always have before. I take one pill each morning for eight more weeks, and then I stop. And then, after a while, for the first time in forever, I become fertile. And then we try to make a baby. Not by doing anything too differently, just with the absence of a tiny little pill each morning. Then perhaps, one day, almost out of the blue, we become parents. How terrifying.

How do I decide that I'm ready? That I'm all grown up and I know enough about the world to start teaching another? Am I an adult? How did that happen? I don't know how people do it. How they decide that they're good enough. That they're worthy.

The one thing that makes it not completely terrifying, that makes me think that it is also exciting and right, is of course my husband. I've never known anyone like him - so extraordinary. I love him, and I trust him. Not only his heart, but his head. His values, his ethics, his wisdom. I can imagine no better role-model for our child. We are a team, and I don't have to be everything, I just have to be myself. We have so much joy in our life together as two, it would be a delight to make it three. So with him beside me, I think that I might have the courage to soon stop taking these tiny orange pills.